Holistic Approach for Intervention in Geriatric Male Patient with Parkinson’s Disease: A Case Study - Juniper Publishers

Juniper Publishers-Open Access Journal of Case Studies

Holistic Approach for Intervention in Geriatric Male Patient with Parkinson’s Disease: A Case Study

Authored by Neha Tiwari

Abstract

Parkinson’s disease (PD) occurs most often in the people in their 50’s and 60’s. Hypokinetic dysarthria has been reported to occur in 73% of the patients suffering from PD [1]. The disease is closely related to cognitive difficulties such as impaired attention, disorganized thinking, inefficient processing of abstract new/old information. Speech Language Pathologist’s (SLP) role in the intervention of individuals with PD is not limited to working upon speech impairment but also improving various cognitive functions. This case study reflects the importance of inter-professional collaboration between neurologist, SLP along with other professionals and training of caretaker which plays a crucial role in intervention of individual with Parkinson’s disease. Also, SLP’s focus upon cognitive linguistic deficits, augmentative communication method and communication enhancement strategies could result in achieving communication goals.

Keywords: Parkinson’s disease; Hypokinetic dysarthria; Neurologist; Caretaker training; Physiotherapist

Introduction

Parkinson’s disease is a neurodegenerative disorder which is characterized clinically by resting tremor, bradykinesia, rigidity and postural instability. This condition is caused by the loss of neurons in the substantia nigra of the brain. The main communicative disorder associated with Parkinson’s disease is hypokinetic dysarthria. The speech characteristics associated with hypokinetic dysarthria includes marked reduction in the amplitude of voluntary movements, slowness of movements, initiation difficulties, muscular rigidity, loss of automatic (associated) aspects of movements and tremor at rest [2]. Prevalence studies suggest that up to 30% of patients with PD develop dementia. Dementia in PD patients is often a multifactorial condition [3]. Even, in the absence of dementia, several cognitive difficulties are associated with Parkinson’s disease such as impaired attention, perception/memory, disorganized thinking, difficulty processing information, inefficient retrieval of old and stored information, inefficient problem solving. It is crucial to determine how cognitive abilities affect speech and language in geriatric population with PD. Hence, this case study aims to determine the impact of cognitive abilities over language in geriatric population with PD. The role of SLP to determine an effective treatment plan for improving cognitive skills and communication skills is highlighted.

Case Study

The case is 78 years old male referred for speech therapy from Department of Neurology, Bombay Hospital Institute of Medical Sciences on March 2021 with the diagnosis of Parkinson's disease. He was prescribed Tab Admenta 5mg to be taken after lunch and was also advised physiotherapy by the neurologist. A detailed speech and language evaluation was conducted. His oro-motor examination revealed that the strength and range of motion of articulators was affected. Movements of lips and tongue was found to be impaired and rigidity during movements was observed. On the Consensus Auditory-Perceptual Evaluation of Voice (CAPE V), his voice and resonance were found to be abnormal. He was unable to vary pitch and vocal intensity. Upon multiple attempts, he could phonate for the assessment of maximum phonation duration (MPD) and responded for assessment of diadochokinetic rate (DDKR). His MPD was found to be 7 seconds. The DDKR was found to be very slow. During the testing, speech intelligibility was found to be poor with less than 40% intelligibility. His speech was characterized by loss of modulation with an accelerated and or variable speaking rate causing slurring. He also displayed articulatory imprecision resulting in sound distortions. His comprehension (both auditory and reading) ability was found to be impaired. During evaluation of his memory skills, he did display impairment on tasks involving immediate memory. Recall of categories was also found to be affected but he could recall past memories fairly well. His reading and writing skills are also affected. He was found to be hesitant and unwilling to participate in communication esp. when a question would be asked. It was observed that instead of answering questions, he would begin to narrate incidents related to the questions. If unable to answer, he would get frustrated and agitated because of which the session would get frequently disrupted. After detailed speech and language evaluation, he was diagnosed with hypokinetic dysarthria with deficits in cognitive skills. The therapy sessions were through online mode due to the fear of spread of Covid 19. Since, the virtual mode was used, it was very important to counsel his wife and the care taker to remain actively involved during therapy. The therapy plan was directed upon postural stability, relaxation of upper body through various breathing exercises, oro- motor exercises for better oro-motor functioning. The exercises were demonstrated to the caretaker to be done every day. Cognitive Linguistic Improvement Program (CLIP)was followed which consisted of various memory, temporal orientation and categorization tasks. Activities like naming, lexical retrieval, find the missing objects, pick the odd one out, find the differences, maze games, following pattern were also used as cognitive stimulating activities. Caretaker training was also given once for appropriate home-based management. Upon discussion with the caretaker, therapy sessions were planned to be held twice a week. The duration of therapy session was 40- 50 minutes. 13 online sessions were taken. The caretaker was also counselled regarding use of pictures and test cards as an augmentative communication method.

Results

There has been regular communication between neurologist, Physiotherapist and SLP regarding goals, activities and improvement. The client has been showing improvements in various aspects of cognition that were affecting language. The use of CLIP by SLP in managing cognitive linguistic deficits along with the pharmacological treatment is helping the client’s cognitive capabilities thereby increasing the use of language and interest to communicate. The patient’s frustration has reduced drastically. Care taker training is regularly done as a result of which the caretaker is now able to provide proper home-based management for the client and has a better understanding of the client’s special needs related to Parkinsonism. Constant guidance and counseling are provided by the speech therapist to the client, family members and caretaker. The speech intelligibility has improved to 60% due to various strategies like stressing, slow rate of speech and breaking words into syllables while speaking.

Conclusion

It is important to have a holistic approach in which cognitive, motor (fine and gross) as well as communication difficulties should be managed by a team including neurologist, physiotherapist, SLP and caretaker in management of PD. SLPs role is highlighted in this case study. SLPs are involved in planning & working upon communication goals, guidance of care taker and care taker training. A structured caretaker is recommended in the present case study.

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Is there a Link between Depression and Morgagni-Stewart-Morel Syndrome? About a Clinical Case- Juniper Publishers

Juniper Publishers-Open Access Journal of Case Studies

Is there a Link between Depression and Morgagni-Stewart-Morel Syndrome? About a Clinical Case

Authored by Smaoui Najeh

Abstract

Morgagni Stewart Morel (MSM) syndrome is an association of clinical features with radiological findings. It is defined as the presence of hyperostosis frontalis interna, variably associated with metabolic, endocrine, and neuropsychiatric disorders. In the literature, the majority of reported cases presented with depression, without any studies focusing on researching the nature of the link between the two types of disorders. In fact, depression raises the question of whether it is related to the Disease or to the elderly since the prevalence of the MSM syndrome increases with age. There is considerable debate in the scientific community as whether to the depression is a comorbidity or a clinical manifestation of this syndrome. In this work, we report a clinical case to discuss the relationship between MSM syndrome and depression in a 67-year-old woman who presented with depression and Imaging consistent with MSM syndrome.

Keywords: Morgagni-stewart-morel syndrome; Depression; Comorbidity; Co-occurrence; Relationship

Introduction

Morgagni Stewart Morel (MSM) syndrome was first described by Morgagni, during autopsy, in an obese female patient who had hirsutism and thickening of inner table of her skull. Stewart, in 1928, and Morel, in 1930, added neuropsychiatric symptoms [1]. Due to the frequency of endocrinal dysfunctions, it was also called metabolic craniopathy. The symptoms are generally non specific and benign, but they may cluster together in some cases, giving rise to various syndromes. This disease is usually misdiagnosed.

In the literature [2], the majority of reported cases presented with psychiatric disorders, in particular depression, without any studies focusing on researching the nature of the link between the two types of disorders. In fact, depression raises the question of whether it is related to the disease or to the elderly since the prevalence of the MSM syndrome increases with age. We report a clinical case to discuss the relationship between MSM syndrome and depression.

Case Report

A 67-year-old woman was referred to our outpatient psychiatry department for persistent affective symptoms during three years, which had gradually worsened in the latest month. She also was suffering from diabetes and high blood pressure, well-balanced under treatment. There was no family history of psychiatric or neurological disorders.

In fact, she suffered from depressed mood, loss of initiative, decreased appetite, anxiety, difficulty staying asleep, and lack of energy and motivation. Over the years, she had gradually withdrawn from social activities.

She was overweighted (body mass index 31kg/m2) with blood pressure: 140/80mm Hg. She looked tired with under-eye dark circles and reduced facial expression. She reported being sad, with anhedonia and panic attacks. There was neither suicidal ideations nor psychotic symptoms. She was vigilant and cooperative. There were no focal neurological symptoms. Her Mini Mental State Exam (MMSE) and Geriatric Depression Scale (GDS) scores were 26/30 and 13/15 respectively.

Routine blood chemistry showed hyperglycemia at 1.46g/l. A brain computed tomography showed bilateral and symmetrical frontal bone hyperostosis centered on the inner table (Figure 1). No parenchymatous or vascular lesions were objectivized. Possible secondary causes were excluded by investigating acromegaly, malignity, Paget’s disease, neuroendocrine tumours, and hyperparathyroidism. The diagnosis of MSM syndrome was retained.

We prescribed selective serotonin reuptake inhibitor (SSRI) antidepressant (Sertraline 50mg/day) for depressive symptoms. A therapeutic adjustment with hygiene and dietetic rules was made. A neurosurgical opinion was sought and concluded that no immediate surgical intervention was indicated.

After three months, there was a noticeable improvement in mood and sleep disorders with resumption of certain activities. Her GDS score became 8/15.

Discussion

MSM syndrome is an association of clinical features with radiological findings. It is defined as the presence of hyperostosis frontalis interna (HFI), variably associated with metabolic, endocrine, neurological and psychiatric disorders [3,4]. The common clinical features are virilism, diabetes, abdominal adiposity, high blood pressure, pituitary disorders (polyphagia, polydypsia, visual disturbances, asthenia) and neurological disorders (headache, migraine, comitial seizures, cognitive impairments, parkinsonism) [5,6]. In the literature [2], psychiatric symptoms have had various manifestations; behavioral disturbances, psychotic symptoms, character change, aggression, suicide attempts, and mainly depression. Our patient presented with a partial expression of MSM symptoms, with depressive disorder in the foreground, metabolic and endocrine disorders (high blood pressure, obesity, diabetes) and HFI on imaging.

Its prevalence in autopsy series is 12%, affecting mainly women, and increasing with age [4], which is the case of our patient. Also like in our clinical case, its discovery is often incidental, either in isolation or associated with disease states. The diagnosis relying on imagery. The characteristic X-ray finding is thickening of inner table of skull [1]. The exact etiology of HFI and MSM syndrome remains unclear. The most interesting theories relate to sex hormones dysregulation, obesity and leptin dysfunction that promoted osteoformation [7,8]. Genetic basis was hypothesized in a case report of monozygotic twins both suffering from MSM syndrome [8]. However, the symptoms were non uniform between them, suggesting phenotypic variability probably due to environmental factors. In practice, doctors are confronted primarily with the “fragments” of the disease, because this syndrome develops its symptoms for many years and at different speeds [9]. But in some cases, they may cluster together, giving rise to delay in diagnosis and treatment.

There is considerable debate in the scientific community as whether to the psychiatric syndrome is a comorbidity or a clinical manifestation of this syndrome. Some authors classify the psychiatric symptoms as ancillary signs because they are heterogeneous, inconstant and almost always present in elderly due to senility [4]. Other authors [9] think there is a clear association between HFI and psychiatric disorders. Future studies aiming to clarify their relationship are necessary to determine if the psychiatric symptom is a primary or secondary manifestation of MSM syndrome. Mental disorders, especially depression may be secondary to the endostosis and its mechanical effects on the one hand. On the other hand, the prevalence of depression in the general population is high, and HFI is quite a common finding nowadays [10]. Therefore, the combination of these two conditions is not unusual. Nevertheless, studies revealed an increased incidence of HFI in mental hospital patients regardless of age [11]. Indeed, the infundibulo-pituitary region is the center of endocrine regulation. It is also involved in psychiatric disorders. Moreover, among the etiopathogenic hypotheses of depression, the endocrine disturbance play a key role, notably sex hormone and leptin dysfunctions which involved in MSM syndrome [12]. All of this could justify depression as a primary manifestation in MSM syndrome.

So, we presume that there was a relationship between our patient’s depressive disorder and her HFI. However, the cause-effect relationship of these association remains unclear. Pathological changes in the brain and cranial box, as well as endocrine imbalance, can contribute to neuropsychiatric disorders, especially depression [2,9]. Anyway, as well as in our case-report, the psychiatric disorder may be improved by specific treatment.

Conclusion

MSM syndrome is one of the less understood syndromes. The patient may present with varied symptoms and thus lead to difficulty in diagnosis. Whatever, depression should be interpreted not only as component of MSM syndrome, but also as a comorbidity of this syndrome. The psychiatric comorbidities, including depression, whether or not related to the disease, are likely to be improved by appropriate treatment.

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