Healthy Older Man Who Tells Fabricated Stories

Image ©SpeedKingz/Shutterstock.com

THE CASE

A 68-year-old man who has been reasonably healthy throughout his life is brought in by his daughter for a checkup. He is very concerned about his health and exhibits some features of hypochondriasis. He suggests that he may have liver failure, cancer, and glaucoma, although he has no symptoms of these conditions and has no medical history to suggest that he is at risk for any of them.

History

His daughter asks to speak with the physician privately and says that her father often tells stories he has heard about someone else as if they had happened to him. For example, the patient’s friend recently received a diagnosis of hepatocarcinoma, and he has several acquaintances who have been treated for glaucoma. The patient has also told his daughter that his taxes were audited when they were not. As with the health problems, he has an acquaintance whose taxes were audited.

Physical examination

The patient is alert, oriented, cooperative, and pleasant.

He is able to count to ten backward and forward and is proud that he does it accurately. He draws a clock with the correct numbers, leaves appropriate spacing between the numbers, and places the hands to indicate that the time is ten past ten, as requested.

However, he is not able to give directions to his house from the doctor’s office, although he appears to try. He also cannot recall the office suite number, the name of the street of the office address, or the time of his appointment.

His neurological examination is normal for strength, sensation, reflexes, and coordination. His cranial nerve examination is normal with one exception: he is not able to smell either cotton that was soaked in alcohol or the scent of mint. He does not think that this deficit is unusual, but his daughter mentions that he has a long-standing gardening hobby and has been able to identify scents of plants throughout his life.

His gait is normal, and he is able to perform a tandem walk without difficulty.

Eye examination is normal, without signs of glaucoma. Chest is clear, pulse is normal, heart sounds are regular, and the abdomen is non-tender and not distended. His skin appears normal.

Interestingly, the television in the waiting room of the doctor’s office has been showing a program about the dangers of not changing smoke alarm batteries. The patient mentions to his daughter and to the physician that his own smoke alarm at home has been beeping to indicate a dead battery and that he wants to replace the battery as soon as possible.

Diagnostic tests

A complete blood cell count and electrolyte test results are normal. Liver enzyme test results are also normal.

A brain MRI scan is ordered.

To what diagnosis do the clinical findings point?

See next page for MRI findings and the diagnosis. >

DIAGNOSIS: DEMENTIA

The brain MRI scan showed several small chronic gray and white matter infarcts bilaterally, as well as an appearance of atrophy of the bilateral frontal lobes.

The patient received diagnoses of both vascular dementia and degenerative dementia. Although Alzheimer disease was not diagnosed, his physician said that it could not be ruled out. The patient’s poor sense of smell supported the diagnosis, as this deficit can accompany degenerative dementia, including Alzheimer disease.

His stories, which can be described as confabulation, were deemed a result of his dementia. The stories were all related to some type of event that the patient had heard about, and he often believed that the stories had happened to him.

Outcome of this case

The diagnosis of dementia was explained to the family, and they were referred to social work services to help them decide on a safe living arrangement, as the patient was living with his wife, who had limited mobility due to rheumatoid arthritis.

The family began to remind the patient that many of the stories he told did not happen to him. After a few months, the family reported that he was telling fewer false stories. He also became reserved and showed signs of depression, and his interactions with others declined over time.

Discussion

Dementia can manifest in a number of ways, including personality changes, memory impairment, confusion, and confabulation. In general, confabulation is often associated with Korsakoff syndrome,¹ which is alcohol-related dementia, but it can occur with dementia that is associated with atrophy or degeneration of the frontal lobe as well.²

This patient had a decline in his memory. He was able to vaguely recall information and stories about others, but he could not easily distinguish between events that had happened to him and events that had happened to others. He also was particularly concerned with stories about health and safety risks, as these types of stories were more likely to capture his attention and were memorable for him.

When his family informed him that he was telling incorrect stories, he withdrew and stopped interacting. His awareness of his own dementia caused him to become depressed.

Take-home points

• Memory impairment can cause forgetfulness and can also result in false stories as a patient’s recent memory becomes muddled, rather than completely absent.

• A patient’s awareness of his or her own dementia often contributes to depression.

• Vascular dementia is not always accompanied by physical neurological deficits.

• A patient can have both vascular dementia and degenerative forms of dementia.

References:

1. Rensen YC, Oosterman JM, Walvoort SJ, et al. Intrusions and provoked and spontaneous confabulations on memory tests in Korsakoff's syndrome. J Clin Exp Neuropsychol. 2017;39:101-111. doi: 10.1080/13803395.2016.1204991.

2. Yamaguchi H, Maki Y, Yamaguchi T. A figurative proverb test for dementia: rapid detection of disinhibition, excuse and confabulation, causing discommunication. Psychogeriatrics. 2011;11:205-211. doi: 10.1111/j.1479-8301.2011.00370.x.