33.1 Clinical History – Main Complaint

Ms. L is having a regular ongoing follow-up with a psychiatrist in private practice for a history of bipolar disorder (BP). She reported a first major depressive episode at the age of 17 as well as one manic episode several years later. She had a last depressive episode 10 years ago and is currently stabilized under antipsychotic medication. Before being prescribed antipsychotics, she was under sodium valproate medication. She also reported a suicide attempt at the age of 11. In addition to her BP, she reported a dysthyroidia treated with L-thyroxine.

Current medications: aripiprazole (Abilify®), L-thyroxine, cyproterone acetate (androcur®), biperidene chlorhydrate (akineton®).

Her main complaints, motivating the initial consultation, are memory disturbances for recent facts associated to attention and concentration disturbances, as well as phonemic and semantic paraphasia. Due to the reported disturbances, she should note everything she does, and, according to her children, constantly repeats the same things. All these symptoms started 2 years ago.

33.2 General History

Mrs. L (aged 55 at the first consultation) is married and has two children; she is currently working as a sculptor.

33.3 Family History

One grandmother had a probable Alzheimer’s disease at the age of 60.

33.4 Examination

She appeared very anxious during the first consultation at both the testing and interview with a noticeable slowdown in thoughts, especially when initiating new tasks during the neurocognitive assessment, which showed the following results:

• 
  

  Mini Mental State Exam (MMSE): 30/30

  
  
• 
  

  Free and Cued Selective Reminding Test (Grober and Buschke): total score 48/48, immediate free recall 31/48, delayed free recall 16/16

  
  
• 
  

  Frontal Assessment Battery: 17/18 (normal performances)

  
  
• 
  

  Rey figure: memory score 15/36 (p < 10), 113 s (pathological performances)

  
  
• 
  

  Trail Making Test A: 30s (p50), Trail Making Test B: 66s (p50) (normal performances)

  
  
• 
  

  Verbal Fluency: phonemic category: 12 responses (norms 20.57 ± 5.99) (pathological performances)

  
  
• 
  

  Digit Span: forward 5; backward 4

The neuropsychological assessment showed preserved abilities in most cognitive domains such as episodic memory, but mild disturbances on executive functions (measures of working memory, retrieving information from memory) and visual memory. Otherwise on fluency tests, the production was also reduced.

33.5 Special Studies

Blood analysis: TSH: 1.294 mUI/L, T4: 18.2 pmol/L, T3: 4.39 pmol/L.

Brain MRI showed a mild cortical and subcortical atrophy without medial temporal and hippocampal atrophy.

The cerebrospinal fluid (CSF) analysis showed the following results:

• 
  

  Tau: 159 pg/L (N: 100–300 pg/L)

  
  
• 
  

  Abeta: 1015 pg/L (N: 500–1500 pg/L)

  
  
• 
  

  Ptau: 38 pg/L (N < 60 pg/L)

  
  
• 
  

  IATI score: 2.37

  
  
• 
  

  Protein 14-3-3: negative

  
  
• 
  

  Anti-central nervous system antibodies:

  
  
  
  
  • 
    

    Anti-rNMDA: negative

    
    
  • 
    

    Anti-LGI1: negative

    
    
  • 
    

    Anti-CASPR2: negative

  
  
• 
  

  Neuropil: atypical neuronal marking

The patient additionally performed an objective evaluation of the physical activity patterns using an ambulatory accelerometer (seven consecutive 24-h periods using a wrist-worn device on the non-dominant wrist) that did not reveal any changes in the rest-activity cycles.