Cases That Test Your Skills

Depressed and cognitively impaired

Current Psychiatry. 2023 May;22(5):42-46 | doi: 10.12788/cp.0362

References

1. Nussbaum PD. (1994). Pseudodementia: a slow death. Neuropsychol Rev. 1994;4(2):71-90. doi:10.1007/BF01874829

2. Kang H, Zhao F, You L, et al. (2014). Pseudo-dementia: a neuropsychological review. Ann Indian Acad Neurol. 17(2):147-154. doi:10.4103/0972-2327.132613

3. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed, text revision. American Psychiatric Association; 2022.

4. Brodaty H, Connors MH. Pseudodementia, pseudo-pseudodementia, and pseudodepression. Alzheimers Dement (Amst). 2020;12(1):e12027. doi:10.1002/dad2.12027

5. Sekhon S, Marwaha R. Depressive Cognitive Disorders. StatPearls Publishing; 2022. https://www.ncbi.nlm.nih.gov/books/NBK559256/

6. Brown WA. Pseudodementia: issues in diagnosis. Psychiatric Times. April 9, 2005. Accessed February 3, 2023. www.psychiatrictimes.com/view/pseudodementia-issues-diagnosis

7. Kulas JF, Naugle RI. (2003). Indications for neuropsychological assessment. Cleve Clin J Med. 2003;70(9):785-792.

8. Braun M, Tupper D, Kaufmann P, et al. Neuropsychological assessment: a valuable tool in the diagnosis and management of neurological, neurodevelopmental, medical, and psychiatric disorders. Cogn Behav Neurol. 2011;24(3):107-114.

9. Michels TC, Tiu AY, Graver CJ. Neuropsychological evaluation in primary care. Am Fam Physician. 2010;82(5):495-502.

10. Wiemels J, Wrensch M, Claus EB. Epidemiology and etiology of meningioma. J Neurooncol. 2010;99(3):307-314. doi:10.1007/s11060-010-0386-3

11. Gyawali S, Sharma P, Mahapatra A. Meningioma and psychiatric symptoms: an individual patient data analysis. Asian J Psychiatr. 2019;42:94-103. doi:10.1016/j.ajp.2019.03.029

12. McAllister TW. Neurobehavioral sequelae of traumatic brain injury: evaluation and management. World Psychiatry. 2008;7(1):3-10. doi:10.1002/j.2051-5545.2008.tb00139.x

13. Bommakanti K, Gaddamanugu P, Alladi S, et al. Pre-operative and post-operative psychiatric manifestations in patients with supratentorial meningiomas. Clin Neurol Neurosurg. 2016;147:24-29. doi:10.1016/j.clineuro.2016.05.018

14. Devinsky O, Barr WB, Vickrey BG, et al. Changes in depression and anxiety after resective surgery for epilepsy. Neurology. 2005;65(11):1744-1749. doi:10.1212/01.wnl.0000187114.71524.c3

15. Blumer D, Wakhlu S, Davies K, et al. Psychiatric outcome of temporal lobectomy for epilepsy: incidence and treatment of psychiatric complications. Epilepsia. 1998;39(5):478-486. doi:10.1111/j.1528-1157.1998.tb01409.x

16. Glosser G, Zwil AS, Glosser DS, et al. Psychiatric aspects of temporal lobe epilepsy before and after anterior temporal lobectomy. J Neurol Neurosurg Psychiatry. 2000;68(1):53-58. doi:10.1136/jnnp.68.1.53

The authors’ observations

Patients who require neurosurgery typically already carry a heavy psychiatric burden, which makes it challenging to determine the exact psychiatric consequences of neurosurgery.^12-14 For example, research shows that temporal lobe resection and temporal lobectomy for treatment-resistant epilepsy can lead to an exacerbation of baseline psychiatric symptoms and the development of new symptoms (31% to 34%).^15,16 However, Bommakanti et al¹³ found no new psychiatric symptoms after resection of meningiomas, and surgery seemed to play a role in ameliorating psychiatric symptoms in patients with intracranial tumors. Research attempting to document the psychiatric sequelae of neurosurgery has had mixed results, and it is difficult to determine what effects brain surgery has on mental health.

OUTCOME Minimal improvement

Several weeks after neurosurgery, Ms. X and her family report her mood is improved. Her PHQ-9 score improves to 15, but her GAD-7 score increases to 13, 1 point above her previous score.

The treatment team recommends Ms. X continue taking sertraline 50 mg/d and trazodone 50 mg/d at bedtime. Ms. X’s family reports her cognition and memory have not improved; her MoCA score increases by 1 point to 23. The treatment team discusses with Ms. X and her family the possibility that her cognitive problems maybe better explained as a neurocognitive disorder rather than as a result of the meningioma, since her MoCA score has not significantly improved. Ms. X and her family decide to seek a second opinion from a neurologist.

Bottom Line

Pseudodementia is a term used to describe older adults who present with cognitive issues in the context of depressive symptoms. Even in the absence of focal findings, neuroimaging should be considered as part of the workup in patients who continue to experience a progressive decline in mood and cognitive function.

Related Resources

Moller MD, Parmenter BA, Lane DW. Neuropsychological testing: a useful but underutilized resource. Current Psychiatry. 2019;18(11):40-46,51.
Pollak J. Psychological/neuropsychological testing: when to refer for reexamination. Current Psychiatry. 2021;20(9):18- 19,30-31,37. doi:10.12788/cp.0157

Drug Brand Names

Citalopram • Celexa
Clonazepam • Klonopin
Duloxetine • Cymbalta
Fluoxetine • Prozac
Sertraline • Zoloft
Trazodone • Oleptro
Venlafaxine extended- release • Effexor XR

References

1. Nussbaum PD. (1994). Pseudodementia: a slow death. Neuropsychol Rev. 1994;4(2):71-90. doi:10.1007/BF01874829

2. Kang H, Zhao F, You L, et al. (2014). Pseudo-dementia: a neuropsychological review. Ann Indian Acad Neurol. 17(2):147-154. doi:10.4103/0972-2327.132613

3. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed, text revision. American Psychiatric Association; 2022.

4. Brodaty H, Connors MH. Pseudodementia, pseudo-pseudodementia, and pseudodepression. Alzheimers Dement (Amst). 2020;12(1):e12027. doi:10.1002/dad2.12027

5. Sekhon S, Marwaha R. Depressive Cognitive Disorders. StatPearls Publishing; 2022. https://www.ncbi.nlm.nih.gov/books/NBK559256/

6. Brown WA. Pseudodementia: issues in diagnosis. Psychiatric Times. April 9, 2005. Accessed February 3, 2023. www.psychiatrictimes.com/view/pseudodementia-issues-diagnosis

7. Kulas JF, Naugle RI. (2003). Indications for neuropsychological assessment. Cleve Clin J Med. 2003;70(9):785-792.

9. Michels TC, Tiu AY, Graver CJ. Neuropsychological evaluation in primary care. Am Fam Physician. 2010;82(5):495-502.

10. Wiemels J, Wrensch M, Claus EB. Epidemiology and etiology of meningioma. J Neurooncol. 2010;99(3):307-314. doi:10.1007/s11060-010-0386-3

11. Gyawali S, Sharma P, Mahapatra A. Meningioma and psychiatric symptoms: an individual patient data analysis. Asian J Psychiatr. 2019;42:94-103. doi:10.1016/j.ajp.2019.03.029

12. McAllister TW. Neurobehavioral sequelae of traumatic brain injury: evaluation and management. World Psychiatry. 2008;7(1):3-10. doi:10.1002/j.2051-5545.2008.tb00139.x

14. Devinsky O, Barr WB, Vickrey BG, et al. Changes in depression and anxiety after resective surgery for epilepsy. Neurology. 2005;65(11):1744-1749. doi:10.1212/01.wnl.0000187114.71524.c3

Disrupted gut microbiome a key driver of major depression?

Depressed and cognitively impaired

References

The authors’ observations

OUTCOME Minimal improvement

Bottom Line

Related Resources

Drug Brand Names

Pages

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