"Spells"- a clue in elderly patients

Dr. Manley presented a case of an elderly man with history of dementia and visual hallucinations (small children running around) who was admitted for “spells”. These spells were short lived, characterized by sudden staring off, occasional atonia, occasional urinary incontinence, some extremity jerking and absence of post-ictal state.

…. Does this illness script jog anyone’s memory?

What if I told you that this was his orthostatic vitals:

  • Lying: 107/64, HR 82

  • Standing 1 min: 97/50, HR 84

  • Standing 3 min: 79/42, HR 86

…Anything strike you about the heart rate?


Now what's on your differential for neurodegenerative disease + autonomic failure?

  • PARKINSON’S DISEASE: motor symptoms predominate, 20-60% patients will develop autonomic failure

  • LEWY BODY DEMENTIA: next slide

  • MULTIPLE SYSTEMS ATROPHY: dysautonomia, motor symptoms, oculomotor issues, and urinary incontinence- challenging to differentiate from Parkinson’s. Preserved cognitive function + minimal response to Levodopa are clues

  • PURE AUTONOMIC FAILURE: isolated dysautonomia without other symptoms, good prognosis

This patient had likely LEWY BODY DEMENTIA! We characterized these “spells” as “cognitive fluctuations”.

“like” this post if you got the diagnosis right!