Case 16 – Middle-Aged Man Looking for Words

Abstract

The patient is a 58-year-old-right-handed man, with 11 years of schooling. A retired bank manager, he presented in May 2011 with a 3-year history of progressive word-finding difficulties and phonological errors in spontaneous speech.

Case 16 Middle-Aged Man Looking for Words

Aline Carvalho Campanha , Mirna Lie Hosogi , Ricardo Nitrini , and Paulo Caramelli

16.1 Clinical History – Main Complaint

16.2 General History

According to the patient and his wife, he started to present with word-finding difficulties and changes in the sounds of words during speech in the last 3 years. His wife emphasized that his language alterations were the main symptoms for the initial phases of the disease. She observed that in the beginning he presented errors in spontaneous speech, could not finish sentences, and became progressively quieter and silent.

He avoided answering the phone and talking to his friends and relatives. At home, his family reported that besides the difficulties in verbal communication, he was no longer as emotive as he always had been. He was fully independent for daily life activities. During the last years working as a bank manager, he had to change function because of his communication difficulties, up to the point that he decided to retire.

16.3 Family History

The patient did not report any case of cognitive impairment or dementia in his family. His wife mentioned that he had slight learning disabilities during his childhood.

16.4 Assessment, Imaging and Test

The patient underwent the following tests:

16.4.1 Clinical Consultation and Neurological Examination

The present evaluation occurred 3 years before the beginning of the symptoms and was initially exclusive of language.

During the interview, the patient displayed several mistakes regarding personal facts, loss of objectivity, and difficulty in concentrating. His speech was marked by pauses and paraphasias, with naming difficulties. He had problems in keeping the contents of the conversation. Moreover, his wife reported difficulties to learn how to use home appliances and to express opinions verbally. Behavioral changes were also reported, such as anxiety, disinterest, social isolation, and lack of motivation. Sleep and appetite were preserved, although with preference for sweets. Delusions and hallucinations were absent.

Past medical history included only arterial hypertension. The patient was under regular drug treatment with hydrochlorothiazide (25 mg/day) and citalopram (20 mg/day).

On neurological examination, there were no motor or sensory deficits. Balance and gait were unremarkable. No signs of parkinsonian syndrome were detected. Cranial nerves were normal.

16.4.2 Cognitive and Functional Evaluations

The patient scored 21/30 in the Mini-Mental State Examination (MMSE); errors occurred in orientation to time/place, language, and memory tasks. He had difficulties in the clock-drawing test (Figure 16.1).

Figure 16.1 Patient’s performance in the clock-drawing test (requested time – 2:45).

He scored 98/144 points in the Mattis Dementia Rating Scale (DRS). This score is below the Brazilian norms for the patient’s educational level (i.e., 123/144). The patient displayed difficulties in almost all DRS domains: attention (32/37), initiative and perseveration (17/37), construction (6/6), concept (31/39), and memory (12/25). Episodic verbal memory was significantly impaired, with severe difficulty in immediate and delayed recall in the Rey Auditory-Verbal Learning Test (RAVLT).

Functional evaluation was conducted with the Disability Assessment for Dementia (DAD), with the following results: initiative (10/13 = 76%), planning and organization (8/10 = 80%), effective realization (13/17 = 76%), indicating mild functional impairment, essentially in instrumental activities of daily living dependent on oral communication.

16.4.3 Speech and Language Assessment (Table 16.1)

– Spontaneous speech: The patient was fluent, but the speech was interrupted by pauses, word-finding problems, and phonemic errors, without phonoarticulatory distortions. The syntactic organization was preserved, without signs of agrammatism and without speech apraxia.
– Oral comprehension: Difficulties with comprehension of sentences, short texts and more complex syntactic constructions.
– Word repetition: Preserved from the Boston Diagnostic Aphasia Examination.
– Sentence repetition: Impaired with difficulties on repetition of phrases from the Boston Diagnostic Aphasia Examination.
– Naming: In the Boston naming test, he was able to name only 16 out of 60 items.
– Reading: The patient was able to read irregular and regular words, and also nonwords.
– Writing: He was able to write regular words and simple sentences.
– Buccofacial praxis: He was able to perform single and complex phonoarticulatory sequences.