Meniere s Disease Case. Suzanne Beason-Hazen, Ph.D.

Transcription

1 Meniere s Disease Case Suzanne Beason-Hazen, Ph.D.

2 IDENTIFYING INFORMATION 64-year-old man, 15 years of education (three years of college, did not complete a degree) Employed as airline transport pilot from 1973 through August 2012 syncopal episode in November 2011 Diagnosed with Meniere s disease January 2012 Began taking Lexapro April 2012 Placed on short-term disability in August 2012 for Meniere s disease Referred for neurospychological evaluation according to the SSRI protocol

3 MENIERE S DISEASE VESTIBULAR DISORDER SYMPTOMS VERTIGO HEARING LOSS TINNITUS AURAL FULLNESS BRAIN FOG

4 INITIAL EVALUATION 5/17/13 RESULTS

5 COGSCREEN-AE 2013 LRPV = 1.0 DUE TO POOR PERFORMANCE ON: Math accuracy 10 th percentile Matching to Sample speed 5 th percentile SAT Instruction speed 2.5 th percentile Visual Sequence Comparison speed 5 th percentile

6 REGIONAL PILOT DATABASE SPEED % 90% 80% 70% Percentile 60% 50% 40% 30% 20% 10% 0% ASCRTC DATDRTC DATIRTC DATSCRTC DTTAABS DTTDABS DTTPARTC DTTPDRTC MANRTC MATHRTC MTSRTC PFCRTC PFLRTC PFNRTC SATACRTC SATADRTC SATDIRTC SATINRTC VSCRTC

7 REGIONAL PILOT DATABASE ACCURACY % 90% 80% 70% Percentile 60% 50% 40% 30% 20% 10% 0% ASCACC BDSACC DATSCACC DTTPAACC DTTPDACC MANACC MATHACC MTSACC PFCACC PFLACC PFNACC SATACACC SATADACC SATDIACC SATINACC SDCACC SDCDRACC SDCIRACC VSCACC

8 COGSCREEN-AE 2013 REGIONAL PILOT DATABASE PATTERN OF PERFORMANCE CONSISTENT WITH AGE-RELATED COGNITIVE SLOWING SPECIFICALLY, SPEED AT OR BELOW 5 TH PERCENTILE ON: - Auditory Sequence Comparison*, Math, Matching to Sample, Pathfinder Letter*, Shifting Attention Task Instruction*, and Visual Sequence Comparison* Tasks *Tasks predicting aviation performance

9 COGSCREEN-AE 2013 REGIONAL PILOT DATABASE ACCURACY ABOVE 15 TH PERCENTILE FOR ALL MEASURES EXCEPT: Math 10 TH percentile Matching to Sample 10 th percentile

10 COGSCREEN-AE 2013 REGIONAL PILOT DATABASE BASE RATE ANALYSIS SCORES AT OR BELOW 5 TH PERCENTILE # of scores %ile T-score Speed 6 <2.5 <30 Accuracy 0 >50 >50 Thruput Process

11 COGSCREEN-AE 2013 REGIONAL PILOT DATABASE BASE RATE ANALYSIS SCORES AT OR BELOW 5 TH PERCENTILE # of scores %ile T-score Speed 6 <2.5 <30 Accuracy 0 >50 >50 Thruput Process

12 COGSCREEN-AE 2013 REGIONAL PILOT DATABASE BASE RATE ANALYSIS AT OR BELOW 15 TH PERCENTILE # of scores %ile T-score Speed 13 <2.5 <30 Accuracy Thruput 12 <2.5 <30 Process

13 COGSCREEN-AE 2013 REGIONAL PILOT DATABASE TAYLOR AVIATION FACTOR SCORES T-Score ATTRIBUTE IDENTIFICATION MOTOR COORDINATION VISUAL ASSOCIATION MEMORY SPEED/WORKING MEMORY TRACKING 48.78

14 TRADITIONAL NEUROPSYCHOLOGICAL MEASURES 2013 WAIS-III FSIQ 100, VIQ 113, PIQ 85 VIQ/PIQ DISCREPANCY 0.05, 1.2% C.P. PERCEPTUAL ORGANIZATIONAL INDEX 88 BLOCK DESIGN SS=8 PICTURE COMPLETION SS=7 MATRIX REASONING SS=9 PROCESSING SPEED INDEX 91 DIGIT SYMBOL-CODING SS=7 SYMBOL SEARCH SS=10

15 TRADITIONAL NEUROPSYCHOLOGICAL MEASURES 2013 ATTENTION PASAT 2.8 sec ISI T=38 (Kay Pilot Norms)

16 TRADITIONAL NEUROPSYCHOLOGICAL MEASURES 2013 EXECUTIVE FUNCTIONS COWAT SS=6 (raw=21) (MOANS NORMS) TRAILS B T=37 (TRAILS A T=44) (KAY PILOT NORMS) STROOP COLOR T=31 (ALL OTHER STROOP MEASURES WNL)

17 TRADITIONAL NEUROPSYCHOLOGICAL MEASURES 2013 VISUOSPATIAL FUNCTIONS -ROCF COPY T=26 (KAY PILOT NORMS)

18 TRADITIONAL NEUROPSYCHOLOGICAL MEASURES 2013 VERBAL MEMORY CVLT-II RAW T-SCORE* TRIAL (50) TRIAL (50) TRIALS (46) LONG DELAY 10 36(50) *KAY PILOT NORMS (TEST MANUAL)

19 TRADITIONAL NEUROPSYCHOLOGICAL MEASURES 2013 NONVERBAL MEMORY ROCF RAW T-SCORE* Immediate Delay (51) *KAY PILOT NORMS (SPREEN 98)

20 TRADITIONAL NEUROPSYCHOLOGICAL MEASURES 2013 PSYCHOMOTOR SPEED GPT TIME T-SCORE* DOMINANT NON-DOMINANT *HEATON NORMS

21 CONCLUSIONS 2013 BASED ON SLOWING AND OTHER DEFICITS ON THE COGSCREEN-AE TOGETHER WITH PIQ=85 AND IMPAIRMENTS ACROSS SEVERAL COGNITIVE DOMAINS WHEN COMPARED TO SIMILAR PILOTS (AND FOLLOWING CONSULTATION WITH DR. KAY), SPECIAL ISSUANCE MEDICAL CERTIFICATE NOT RECOMMENDED

22 CASE REVIEW 8/14 RECOMMENDATIONS: 1. ASSESS PRESENCE OF DEVELOPMENTAL LEARNING DISORDER BY: -TEST OF READING FLUENCY -MATH ACHIEVEMENT TESTING -DETAILED REVIEW OF ACADEMIC RECORDS

23 CASE REVIEW 8/14 RECOMMENDATIONS (CONT.) 3. REPEAT WAIS PERCEPTUAL ORGANIZATIONAL INDEX 4. REPEAT COGSCREEN-AE 5. PILOT PERFORM COGNITIVE EXERCISES SUCH AS LUMOSITY TO IMPROVE SPEED AND ACCURACY ON MEASURES OF VISUAL PERCEPTION AND EXECUTIVE FUNCTIONS

24 SECOND EVALUATION JANUARY 2015 RESULTS

25 REVIEW OF ACADEMIC RECORDS LOW AVERAGE TO AVERAGE PERFORMANCE IN BOTH HIGH SCHOOL AND COLLEGE COLLEGE GRADES B S TO D S WITH SOME FAILING GRADES NO GPA BUT ACADEMIC PROBATION NOTED SAT SCORES 320 VERBAL, 357 MATH (1966) 422 VERBAL, 410 MATH (1973)

26 COGSCREEN-AE 2015 LRPV IMPROVED FROM THE INITIAL EVALUATION DUE TO BETTER PERFORMANCE ON: -Matching to Sample Speed: 5 th to 10 th %ile -SAT Instruction Speed: 2.5 th to 20 th %ile -VSC Speed: 5 th to 7.5 %ile -Math Accuracy: 10 th to 42.5th percentile

27 REGIONAL PILOT DATABASE SPEED % 90% 80% 70% Percentile 60% 50% 40% 30% 20% 10% 0% ASCRTC DATDRTC DATIRTC DATSCRTC DTTAABS DTTDABS DTTPARTC DTTPDRTC MANRTC MATHRTC MTSRTC PFCRTC PFLRTC PFNRTC SATACRTC SATADRTC SATDIRTC SATINRTC VSCRTC

28 REGIONAL PILOT DATABASE ACCURACY % 90% 80% 70% Percentile 60% 50% 40% 30% 20% 10% 0% ASCACC BDSACC DATSCACC DTTPAACC DTTPDACC MANACC MATHACC MTSACC PFCACC PFLACC PFNACC SATACACC SATADACC SATDIACC SATINACC SDCACC SDCDRACC SDCIRACC VSCACC

29 COGSCREEN-AE 2015 REGIONAL PILOT DATABASE BASE RATE ANALYSIS SCORES AT OR BELOW 5 TH PERCENTILE # of scores %ile T-score Speed 3(6) 10(<2.5 ) 37(>30) Accuracy 0 >50 >50 Thruput 0(5) 37.5(25) >46(30) Process

30 COGSCREEN-AE 2015 REGIONAL PILOT DATABASE BASE RATE ANALYSIS SCORES AT OR BELOW 15 TH PERCENTILE # of scores %ile T-score Speed 9(13) 5(<2.5) 34(<30) Accuracy Thruput 7(12) 7.5(<2.5) 35(<30) Process 2(3) 40(22.5) 48(42)

31 COGSCREEN-AE 2015 REGIONAL PILOT DATABASE SPEED IMPROVED ON THE FOLLOWING MEASURES INITIALLY AT OR BELOW 5 TH PERCENTILE: -MATH (5 th to 42.5 th percentile) -MATCHING TO SAMPLE (5 th to 10 th percentile) -SAT INSTRUCTION (2.5 th to 20 th percentile)

32 COGSCREEN-AE 2015 REGIONAL PILOT DATABASE TAYLOR AVIATION FACTOR SCORES T-Score ATTRIBUTE IDENTIFICATION 30.91(47.80) MOTOR COORDINATION 66.33(55.00) VISUAL ASSOCIATION MEMORY 38.05(38.53) SPEED/WORKING MEMORY 44.91(40.94) TRACKING 49.74(48.78)

33 COGSCREEN-AE 2015 REGIONAL PILOT DATABASE DECLINE IN ATTRIBUTE IDENTIFICATION: SHIFTING ATTENTION TASK Failures to Maintain Set 3 9 Rule Shifts 7 0

34 TRADITIONAL NEUROPSYCHOLOGICAL MEASURES 2015 WAIS-III PERCEPTUAL ORGANIZATIONAL INDEX improved from: 88 (21 st percentile) to 97(42 nd percentile) Block Design ss=8(10) Picture Completion ss=7(9) Matrix Reasoning ss=9(10)

35 TRADITIONAL NEUROPSYCHOLOGICAL MEASURES 2015 EXECUTIVE FUNCTIONS Raw T-score TRAILS A 32(22) 34(50) TRAILS B 76(111) 37(<0) TRAILS C (29) (38) Stroop Color-Word 52(85) 31(61)

36 TRADITIONAL NEUROPSYCHOLOGICAL MEASURES 2015 MEMORY WAIS-III DIGIT SYMBOL INCIDENTAL RECALL FREE 8(>50 th %ile) 5(10 th %ile) PAIRED 8(25 th %ile) 6(25 th %ile) COGSCREEN-AE SYMBOL DIGIT IR 40 th %ile 40 th %ile SYMBOL DIGIT DR 15 th %ile 5 th %ile

37 TRADITIONAL NEUROPSYCHOLOGICAL MEASURES 2015 NELSON-DENNY READING FLUENCY 26 TH PERCENTILE WRAT-4 COMPUTATION STANDARD SCORE = 111

38 CONCLUSIONS 2015 ALTHOUGH THERE WAS IMPROVEMENT ON SOME COGSCREEN MEASURES AND PIQ, DECLINES IN EXECUTIVE FUNCTION AND NONVERBAL MEMORY CONTINUED TO RAISE CONCERNS REGARDING AVIATION SAFETY IN CONSULTATION WITH DR. KAY, IT WAS RECOMMENDED THAT PILOT PURSUE LUMOSITY OR SIMILAR COGNITIVE EXERCISES AND OBTAIN REEVALUATION AFTER SIX MONTHS

39 THIRD EVALUATION JULY 2015

40 TESTS ADMINISTERED TRAIL MAKING A, B, AND C TACTUAL PERFORMANCE TEST WECHSLER MEMORY SCALE-IV

41 RESULTS JULY 2015 EXECUTIVE FUNCTIONS Raw T-score TRAILS A 32(22)19 34(50)55 TRAILS B 76(111)107 37(<0)3 TRAILS C (29)35 (38)29

42 RESULTS JULY 2015 TACTUAL PERFORMANCE TEST Raw T-score^ Dominant Hand Speed N/A* Non-Dominant Hand Speed N/A* Bilateral Speed 9 48 <0 Memory 7 43 Location 2 40 ^pilot norms *only 6 blocks placed by 10 minutes

43 RESULTS JULY 2015 MEMORY WMS-IV Standard Score %ile Auditory Memory Visual Memory Immediate Memory Delayed Memory 94 34

44 CONCLUSIONS JULY 2015 IMPAIRED SPEED OF PERFORMANCE ON TPT IMPAIRED INFORMATION PROCESSING SPEED WITH DECLINE OVER TIME ON TRAILS B NORMAL PERFORMANCE ON THE WMS-IV SUMMARY: GIVEN DECLINE IN EXECUTIVE FUNCTIONS OVER THE 3 EVALUATIONS, POOR PERFORMANCE ON 2 ADMINISTRATIONS OF THE COGSCREEN-AE, AND IMPAIRED PERFORMANCE ON OTHER TRADITIONAL NEUROPSYCHOLOGICAL MEASURES RELATIVE TO PILOT NORMS, MEDICAL CERTIFICATE NOT RECOMMENDED

45 DR. KAY REVIEW DECEMBER 2015 DR. KAY REVIEWED ALL THREE EVALUATIONS AND CONCURRED THAT IMPAIRMENT OF EXECUTIVE FUNCTIONS AND EVIDENCE OF DECLINE OVER TIME WAS SIGNIFICANT AND TOGETHER WITH THE OTHER AREAS OF COGNITIVE IMPAIRMENT ON THE COGSCREEN-AE, DISQUALIFYING FOR A FIRST- CLASS MEDICAL CERTIFICATE

46 EPILOGUE IN NOVEMBER 2015 WAS CONTACTED BY PILOT S DISABILITY INSURANCE COMPANY QUESTIONING CONCLUSIONS OF THE EVALUATIONS -WHY SYMPTOM VALIDITY TESTING NOT PERFORMED -VARIABILITY OF PERFORMANCE