Patient Evaluation For Lyme Encephalopathy

Dates of Evaluation:  10/05/07 and 10/06/07
Primary Diagnosis:  Lyme disease (088.81)
Cognitive Disorder NOS (294.9)
Date of Diagnosis:  12/04

REASON FOR REFERRAL:  This patient, a fifty year old right handed-man was referred by Bernard Raxlen, MD for neuropsychological evaluation to document current level of cognitive functioning and to assess his ability to meet job-related responsibilities.

MEDICAL OVERVIEW:  The patient was born on August 3, 1954 of a full-length, normal pregnancy and weighed eight pounds, ten ounces.  At birth his lungs were three quarters full of fluid and he reports that he “nearly died” but he was treated with steroids and recovered.  He states that according to his mother, all developmental milestones were met in “above average” time.  At nine or ten months old he had a hernia because he was walking “too soon” according to his mother.  Medical history is remarkable for asthma, bronchitis, measles and chicken pox as a child, ear infections, hay fever, influenza, pneumonia, severe colds and several concussions.  As a child, he had asthma which limited some activities but he still participated in all sports.  The patient began to have increasing problems while flying and was diagnosed with a perforated left ear drum.  Since 2002, he has been treated by Dr. Andrew Parker and his hearing has improved although he still suffers from vertigo and an ongoing tinnitus.  In August and September 2003 he developed lower back pain.  In October, he began to experience flu like symptoms, high fever, nausea and blinding headaches, blurred vision, confusion, disorientation, high blood pressure and increased heart rate.  This patient was diagnosed with a vascular necrosis (left hip) in 2003 and in June 2006 had his second hip replacement surgery; the first occurring in 1994.  In November 2004 he was diagnosed with Lyme disease and multiple co-infections by Dr. Raxlen and begun heavy doses of antibiotics and nutrients to improve his immune system.  While he lost thirty pounds in two months once he was diagnosed and put on medication, he regained the weight.  Of his treatment with Dr. Raxlen, he states, “I’ve improved but nowhere close to fully properly functioning.”  In October 2005, this patient developed a nearly “catastrophic” staph infection as a result of a picc line and was hospitalized after near fatal reaction with his and temperature spiking to 104 degrees.  He was hospitalized for three days until his temperature was brought back to normal.  He had a foot fusion in November 2006 which was treated by Dr Robert Marra and his pain and discomfort have improved.  He was confined to his bed or sofa from the end of 2004 through 2005.  His pain is controlled better now with treatment and he is functioning better physically but explains that most of his cognitive problems and symptoms still exist and have not improved.  He describes his symptoms as “evolving”.

A brain Spect scan conducted on April 30, 2007 revealed “areas of diminished perfusion involving both frontal, both temporal and left parietal lobes but with some improvement since previous study.”

Present Daily Medications: Bicillin shots (2x a week), Mepron (750mg x 2), Fluconazole (100 mg x 2), Armour (60 mg x 1), Lotrel (5/10 x 1), Lexapro (10 mg x 1), Zyrtec (10 mg x 1), Nasacort AQ spray (2 puffs), Ambien (10 mg x 1), Adderall, Lunesta, Piracetam and Zithromax (250 mg x 2).  Dr. Raxlen has treated him with a host of nutrients for his Lyme disease as well.

PRESENTING NEUROPSYCOLOGICAL PROBLEMS:  This patient reports difficulties with short-term memory, planning and organization, multitasking and decision making and reports word-finding problems.  This patient has difficulties communicating, especially verbally and has problems doing and completing paperwork. He has difficulty dealing with household business and he states that his “intelligence seems to be ruined”.  He has noticed a significant inability to read and can now only read newspapers and the internet as he cannot retain as much and is unable to read books currently.  He has difficulty with attention and concentration.  He finds that he is somewhat clumsy since the onset of his condition and has difficulty speaking.  He notes significant memory difficulties, slowed speed of information processing and learning problems.  He reported that it took him nearly two weeks to complete our patient questionnaire.

The patient has noticed changes in his personality and has difficulty in dealing with the cognitive changes that have resulted from his disease.  Since his Lyme diagnosis he gets upset and aggressive, has anxiety and panic attacks, worries more and has become socially withdrawn.  The patient reports that he has long-time friends and that he was a leader interpersonally.  His long time involvement in sports promoted and solidified many food friendships but now he avoids most social situations due to the cognitive and emotional sequelae of his Lyme disease.

He can be somewhat impulsive, moody and his irritability results from his reduced skill in dealing with daily frustrations.  He reports, “I need to be productive and worthwhile again.”  He states, “I’ve tried to note severe issues.  My life has truly been turned upside down in the past three years and I’m trying like hell to recapture the productive, fulfilling, life style previously enjoyed.”  This patient recently lost his long-term disability benefits providing him an unwanted increase in his stress levels.

Once he found a major of interest in college, he became an “excellent award winning dean’s list” student.  This patient has experienced a successful, rewarding career in financial services.

Prior to his disability, this patient enjoyed coaching baseball which he did between 1993 and 2004 but has been unable to do so due to his condition.  He reports that from the age of nine through thirty-seven, he played baseball, basketball, football, etc. constantly but is now unable to participate in these activities.  He previously played golf once or twice a week up until 2004 and would travel to a vacation home in Cape Cod, which he had to sell last fall as he was not able to travel there and maintain the home.

RESULTS:  Tests were administered by Leo J. Shea III, Ph.D., a New York licensed psychologist.  Test and scores appear in the Appendix.
INTELLECTUAL FUNCTIONING:  This patient’s overall intellectual functioning as measured by the Wechsler Adult Intelligence Scale-III (WAIS-III) is in the Superior range with a Full Scale I.Q. sore of 125/95th percentile.  His Verbal Comprehension Index score of 131 is at the 98th percentile (Very Superior); his Perceptual Organization Index score of 107 is t the 68th percentile (Average); his Working Memory Index score of 128 is at the 97th percentile (Very Superior) and his Processing Speed Index score of 76 is at the 5th percentile (Borderline).

Verbal Abilities:  In a professional setting, it is likely that he may have difficulty in formulating an exact and high-level response to a question in a timely fashion and in a manner that would demonstrate his innate Very Superior cognitive skills and knowledge of a subject.

On the Controlled Word Association  Test, requiring the generation of words given phonemic cues within a time limit of 60 seconds per phonemic cue, he scored at the 25th percentile (Average) which is far below his Vocabulary score  (95th percentile) and demonstrates his slowness in generating word knowledge.  This suggests that when he is required to generate verbal responses within defined time limits he will encounter difficulty and exhibit halting communications which in turn will reduce the effectiveness of his presentation.

Likewise, he scored at the 63rd percentile (Average) on Picture Completion, a timed task requiring attention to visual detail to identifying missing parts of pictures.  This represents reduced functioning as it is significantly lower than expected given his innate intellectual ability and his scores on other visual cognitive tasks.  The lower score on this subtest documents weakness in the processing of visual detail and in the patient’s ability to detect essential from nonessential details as items become more complex.

Graphomotor speed, as measured by the D-KEFS Motor Speed subtest, requiring him to connect a series of circles was at the <1st percentile (Extremely Low) significantly lower than expected and reflects slow speed of processing.

His ability to process quickly is demonstrable deficit and impacts his cognitive processing of information.  Thus, his ability to scan and process visual information is significantly below his verbal conceptual ability and must be viewed as a significant deficit.

Conversely, a relative weakness in processing speed may make the task of comprehending novel information more time-consuming and difficult.  This patient’s relative weakness in processing some visual items will limit him in learning and incorporating complex information that is presented too quickly or is too complex.  As a result, he will not consistently be able to keep up with the pace and will miss essential pieces of visual information necessary to inform his decision-making.

Reduced speed of information processing was also documented on the Nelson-Denny reading Test with a reading rate at the 5th percentile (Borderline).  This demonstrates a very significant reduction in verbal processing.  His reading comprehension was also below his innate skill in the Low Average range (23rd percentile) under timed conditions.  When time limits were extended, his comprehension increased to the 62nd percentile (Average).  Thus, even though when he was given extended time, he was far below his Very Superior level of his verbal comprehension intellectual ability.

Attention/Concentration:  On another D-KEFS timed task of attention with a color-word interference condition and with auditory verbal output he scored at the 5th percentile (Borderline) under the color-naming subset, a no-distraction condition where he had to just name the colors of an array of squares.   When he had to then read the names of the colors he scored at the 25th percentile (Average).  His performance on these tasks was accurate but slow and he took time to adapt to the process.  In fact, he may have to visually block out information so that he is not distracted by competing stimuli.  This may be an effective strategy when reading where he may need to cover all but the line he is reading.  Mental control as measured by the Wechsler Memory Scale-III was at the 9th percentile.  While his performance was accurate he again demonstrated his slow speed of processing throughout the task.

Working Memory:  The WAIS-III Working Memory Index (WMI) provides information regarding an individual’s ability to attend to verbally presented information, to hold information temporarily in memory, and then to formulate a response.  This higher-level attention ability is an important prerequisite for many cognitive abilities and is thought to help learning and the processing of complex information.

While there is variability among these subtest scores, there is evidence to support the conclusion that working memory is a relative strength for this patient as compared with his intellectual ability.

Verbal Memory:  There is clear evidence of a reduction in auditory verbal memory compatible with this patient’s report of memory problems.  It is important to keep in mind that reduced auditory processing undoubtedly plays a role in this patient’s ability to remember what he has heard and present himself as an effective manager and communicator.

Visual Memory:  His graphomotor difficulties are most pronounced when he is presented with too much information at once as he needs time to consolidate the information , as demonstrated by his improved delayed and recognition recall.

REASONING AND EXECUTIVE SKILLS:  His performance on this visual conceptual task requiring mental flexibility suggests that while be may have the cognitive ability to explore alternative solutions in his day-to-day life it takes him an extended time to arrive at solutions.  Thus, he needs to frequently review and re-evaluate what he is doing so that he can stay on track. If he is required to quickly solve a problem, such as might be the case in a work situation, he may be at deficit.

This patient’s score on the Watson-Glaser, a timed test of critical thinking and inferential reasoning requiring the reading of short paragraphs was at the 15th percentile (Low Average) when using norms for MBA students.  This task, with its complex reading and verbal analysis requirements, documents this patient’s difficulty performing at a level commensurate with his Very Superior cognitive ability when reading complex information.  His score on this task is approximately two standard deviations below his innate Verbal ability and suggests the problems that he would encounter in decision making when he must deal with complex verbal information and make accurate decisions under the time deadlines.

This patient’s responses on the FrSBe indicate that he is, at the present time, experiencing significant difficulty with initiation (Apathy Subscale).  He is also experiencing significant difficulty with impulse control and unmodulated emotional expression (Disinhibition Subscale).  Difficulties were also noted in sustained attention, planning and organization, sequencing, working memory, mental flexibility, self monitoring and problem solving (Executive Dysfunction Subscale).

SUMMARY AND RECOMMENDATIONS:  Neurocognitive weaknesses and compromised functioning were documented in visual scanning, processing of visual detail, visual attention and concentration especially under distracting conditions, complex auditory verbal processing, aspects of auditory and visual memory, speed of information processing, word-finding ability, analysis  of complex verbal information, ability to maintain a cognitive set and reading rate.