Integrating Neuropsychology and Brain Imaging for a Referral of Possible Pseudodementia: A Case Report

Abstract

The study aimed to highlight the importance of interdisciplinary collaboration and the value for combining normative neuropsychological and neuroradiological measures for clinical purposes. We present the case of "CL," a 65-year-old, right-handed, Caucasian female referred for a neuropsychological evaluation of memory difficulties and depression with the rule-out of pseudodementia. A brain magnetic resonance imaging (MRI) scan was conducted within 24 hours of the neuropsychology exam. Mood measures showed elevated depression and apathy symptoms. The neuropsychological profile showed variable effort, intact comprehension but compromised confrontation naming and verbal memory deficits. Using normative references from 20 female age- and education-matched healthy control peers, CL showed significantly reduced temporal cortex thickness with reduced bilateral hippocampal, right amygdala, and right caudate volumes. Combined data were supportive of a diagnosis of semantic dementia. Examining neuropsychological profiles in combination with neuroimaging standardized metrics relative to peers improved case conceptualization. Standard measures of effort and malingering examined alone and without MRI for the diagnosis of pseudodementia have questionable validity and rationale. We additionally discuss the advantages and limitations/challenges for integrating neuropsychological assessments with normative based MRI brain metrics.

Keywords: Dementia; Effort testing; MRI.; Neuroradiology; Pseudodementia.

Figure 1

Clock Command/Copy Command Condition shows executive errors involving incorrect hand placement (she was instructed to set the time to “10 after 11”) and misaligned numbers (particularly 9, 10, and 11) around the circle of the clock face. Copy Condition has the 12 misplaced, slight misalignment in numbers, and despite seeing a clock model with the numbers inside of the face - CL initially perseverates on her original command condition behavior of putting the numbers outside the clock face.

Figure 2

Cookie Theft Writing Handwriting appears fluid and well-formed. Of note is spelling "stall" instead of "stool". Written answers reveal that only basic visual information about the picture was perceived rather than indicating that CL understood the gestalt of the depicted event.

Figure 3

Raw and standardized z-score values for cortical and subcortical regions. Charts in the left column display raw thickness and TICV-corrected gray and white volumetrics by group. Charts in the right column display normative-based (n = 20) z scores for thickness and gray and white volumes corrected for TICV. Charts in the left column display standard deviations for the control group data whereas those in the right column (z scores) display standard error bars.

Figure 4

Representative Images from CL’s MRI