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Tuesday, September 16, 2014
Sorting through confounds
My mother-in-law has a right-sided hemiparesis, which she has had since birth. Recently, we are noticing changes -- attentional, working memory, poor judgment, poor self-awarness, possible visual cut (terrifying to ride in the car when she is driving) -- that lead us to think she may have had an undetected stroke. Given that she`s always had the hemi-paresis, we are not sure how to approach the subject with them, since we would be saying specifically that she is showing signs of impaired cognitive function. She`s a bright and accomplished individual, and is currently extremely irritable and reactive (her husband has cancer, there are multiple stressors). It would be significantly easier to steer them to the appropriate medical care if her unsteadiness, dyscoordination and slurred speech hadn`t always been there (all noticeably worse now, however). What is my question? I guess it is how to approach the subject, get her around the confounding problem of a lifelong right-sided weakness, and get her to an appropriate assessment of recent changes in cognition and functioning? It`s a muddled question, I`m afraid. Hope you`ve got some suggestions.
Hard question to answer. I'll offer a few suggestions, although I'm sure I cannot provide a definitive answer. First thought: if she is having impaired driving, this is something about which you should take immediate action. If you believe that her vision is impaired, she could do harm to herself or someone else. This may be one way to approach the problem--surely she would not want to kill herself or someone else with poor driving. I believe that you should take immediate action for her safety and welfare, as well as those in your community. It is important to note that some neurological problems that involve the right hemisphere (parietal lobe) may be associated with neglect syndromes where the patient is not aware of their deficit. So for example, is the problem is that she cannot see or ignores the left side of space, then this is consistent with a right hemisphere problem. She might well have a left visual field cut due to problems in the right occipital lobe of the brain, but she will likely not be aware of the problem due to involvement of the nearby right parietal lobe. A neglect syndrome can appear to be a field cut without involving the occipital lobe; this may be impossible to determine clinically. Second thought: with regard to cognition, might want to consider depression as a diagnosis. Depression can impair memory and cognitive function significantly. Treatment for depression may help greatly if the diagnosis is made. It is important to keep a record of cognitive symptoms noticed. It won't be your superficial opinion that she is having cognitive problems if you can support your claim with a list of symptoms (has she missed appointments, forgotten bills, mixed up time, been unable to remember things she normally would have known, forgotten names, made speech errors, forgotten things told to her, repeats questions, had problems with losing things, etc.). Third thought: if people have a neurologic deficit, they can often compensate well to survive with it. But the deficits will get worse if there are other stressors that limit their ability to compensate. For example, someone with a stroke may appear to have fully recovered, but their symptoms might return if they develop an infection. Due to the infection, they are unable to compensate to the same degree, so the stroke symptoms are "uncovered". This may explain some of your mother-in-law's symptoms. Old symptoms, for which she had been well compensated, may be uncovered by stress, poor sleep/fatigue, depression, and inattention to her own health (potential for non-compliance with meds, etc.). It sounds like you might want to have her see a physician for a complete evaluation. It is important to remind her to take care of her own health too--she will not be able to help her husband through his fight with cancer if she ignores her own health. I hope this helps.
Brett Kissela, MD
Assistant Professor of Neurology
Director, Neurology Residency Program
College of Medicine
University of Cincinnati