Senile bradypsychia

Specialty: Geriatrics.

• mental slowing of the elderly
• slow cognitive processing
• senile mental fatigue
• psychomotor retardation of the elderly

Why it occurs

• Chronic cerebral small vessel disease with diffuse leukoaraiosis on MRI
• Clinical or subclinical hypothyroidism in the elderly with central metabolic involvement
• Vitamin B12 and folate deficiency that alters neurotransmitter synthesis and myelination
• Side effect and accumulation of drugs with a high anticholinergic load (first generation antihistamines, benzodiazepines, urinary spasmolytics)
• Late-onset depressive disorder that presents with predominance of cognitive symptoms (depressive pseudodementia)
• Initial phases of neurodegenerative diseases such as Lewy body dementia or Parkinson's disease

Initial workup

Application of the Anticholinergic Burden Scale (ACB) to assess active medications; complete blood analysis with complete blood count, thyroid profile (TSH, free T4), levels of vitamin B12, folic acid, serum electrolytes, urea, creatinine and calcium; Computed Tomography (CT) of the skull or Magnetic Resonance Imaging (MRI) of the brain to evaluate the white matter load and the degree of cortical atrophy; specific neuropsychological tests (Cognitive Mini-Exam, Clock Drawing Test, Trail Making Test parts A and B).

Standard management

• Levothyroxine — start with very low doses of 12.5 mcg to 25 mcg orally per day in the morning on an empty stomach if primary hypothyroidism is confirmed, slowly adjusting every 6-8 weeks according to TSH levels to avoid triggering angina or arrhythmias in patients with silent ischemic heart disease.
• Cyanocobalamin — 1000 mcg intramuscularly weekly for a month and then monthly if severe deficiency is documented due to poor absorption, or 1000 mcg orally daily if absorption is preserved
• Gradual and scheduled suspension of central nervous system depressant drugs or drugs with anticholinergic effects.