Case 1

62yo right handed man, Manager for an engineering firm.

Gradual cognitive decline for 3 years Planning, decision making, word finding, reading, writing, misplacing objects Finding objects (e.g. car keys) even when in plain sight. Seen by Ophthalmologist,WNL. ADLs: Intact, except difficulty with work due to problems reading and typing reports on the computer. Mild navigation problems, not getting lost. Otherwise independent.
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PMHx: Obstructive sleep apnea, not using CPAP. no chronic anhedonia or depression. well-controlled hypertension, hyperlipidemia, chronic back pain, gastro-esophageal reflux, and osteoarthritis. Meds: amlodipine, atorvastatin, dexlansoprazole and cetirizine. Tramadol for management of chronic back pain. Flaxseed oil, glucosamine, chondroitin, a multivitamin, vitamin B complex and garlic supplementation. FamHx: Mother with Vascular dementia Soc Hx: No substance abuse, 14 yrs education
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Physical Exam: Visual acuity and color vision were grossly intact Mild L5 radiculapathy Positive palmo-mental reflex

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Bedside cognitive testing: MMSE 26/30: Pentagon copy (drew squares), writing a sentence minor error Category retrieval: 22 animals in one minute Fund of Knowledge: 5/7 correct

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MOCA 21/30:

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Physical Exam: Cortical Vision:
No prosopagnosia, neglect or simultagnosia

Bisecting lines, and identifying symbols on a page

symetrical, but slower on right side of page

Difficulty with picture interpretation and object identification: Self corrected with time and prompting e.g. This is either French fries or carrots
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Working Diagnosis: MCI: Lewy Body Disease, AD-posterior cortical variant, Vascular, non-neurodegenerative (space occupying lesion, NPH, ,etabolic, etc) Tests: Labs: CBC, CMP, B12, TSH Repeat Sleep study for OSA MRI brain Formal Neurocognitive testing
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Labs: normal Repeat Sleep study: OSA resolved MRI (Brain, non-contrast):
moderate atrophy of the hippocampi global atrophy with a posterior predominance There was no significant cerebrovascular disease.

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Formal Neurocognitive testing: Impaired concentration, attention and decision making, symbol digit identification Poor calculations Impaired visual memory, but recall of encoded items intact Visual-motor speeds reduced Difficulty with complex figure copy Semantic language mildly impaired, mild anomia Low avg verbal memory, normal logical memory

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Clinical diagnosis: MCI: AD-posterior cortical variant Lewy Body Disease (no EPS, RBSD) Other non-neurodegenerative

Next Steps: Consider FDG PET and/or Amyloid PET

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Biomarker-based diagnostic assessment:
Amyloid PET (evidence of A)

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Biomarker-based diagnostic assessment:
FDG PET (evidence of Neuronal Dysfunction)

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Final NIA-AA Clinical diagnosis: MCI due to AD with two biomarker evidence: AD-posterior cortical variant

Outcomes: Discussed role of current approved meds for AD in MCI Referred to support services and educational resources Discussed AD research opportunities Follow clinically for cognitive decline, mood disorders, behavioral changes

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Case 2
62yo right handed women, HR dept manager for the US state department, Russian translator.
Short term memory decline for 5 years forgetfulness to events and conversations and occasional repetition mild delayed word-finding increased dependence on calendars

ADLs: Intact, remains independent with increased effort

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PMHx: Mild depression/anxiety, B12 deficiency Meds: B12 QD, MCI, Levapro, asa 81mg FamHx: No family history of dementia Physical Exam: No abnormalities Bedside cognitive testing:
MMSE 30/30, MOCA 27/30 (2/5 on recall) 9 animals in 1 minute AVLT: total score 37, 7/15 words on delayed recall
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Working Diagnosis:
MCI possibly due to AD

Tests: Labs: CBC, LFTs, B12, TSH MRI Brain Neurocognitive testing

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Labs: Normal Neurocogntive testing: mild decreased delayed recall and visual perceptual skills, good attention.

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MRI: No significant atrophy. 2 Venous cavernous angiomas in the medial basal frontal lobe and anterior rostral caudate. Surrounding hemosiderin staining.

GRE Heme

FLAIR

T1 post gad
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Clinical diagnosis: MCI: possible AD vs MCI due to structural brain lesion Next step? Amyloid imaging

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Biomarker-based diagnostic assessment
Amyloid PET (negative for A)

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Final Diagnosis and recommendations:

Mild Cognitive Impairment, non-AD Recommendations: Follow clinically for decline Repeat MRI in 6 and 12 months Discuss risk of bleeding Stop taking aspirin