What does lyme Cognitive Dysfunction look like?

When physicians ask patients questions, they listen to the answers and beyond.  Speech cadence, recognition of concepts, congruent answers and many other every day, non-verbal motor movements and responses subtly reveal a wealth of detailed data on health condition.

Of all the diagnostic tools available to physicians, only asking questions allows the physician to mine an amazingly rich repertoire of irrational sensations and intuitions designed into humans over countless years of evolution, to help humans survive and care for their health when seeking rational experts wasn't an option.

When lyme has reached the brain, this rich 'human data' becomes saboteur, often misleading patient and physician into finding no illness.  Questioning the ill mind is always difficult.  As with other illnesses of the mind, the suffer can be giving information which makes sense, but isn't correct.  For a physician this is terrifying, their most sensitive specific instrument is faulty and its unclear when it can be trusted. 

Cognitive symptoms can be the stuff of nightmares - unable to speak or while being attacked, things appear out of no where, time is lost, the familiar becomes strange and threatening.  Understanding how attention, mental tracking, memory, language, reasoning and neurological processing errors can manifest in a normal physician interview may help better identify cognitive defects of lyme.


Affected areas hard to test in a basic physician interview, here are some thoughts:



Attention and Mental Tracking - sustained attention is the key here, look for follow through here over several minutes, over several though/concept transitions.  Comprehension of cause and effect can be fragmented.  A patient's thoughts may vanish as soon as they become aware they are thinking them. 

TEST:  Give a series of 5 - 7 things in a cause and effect relationship, then ask a question about one of the relationships - which caused what.



Memory - retaining new information may become difficult after a distinct date/event in the patient's history and/or new concepts, stories or items may be difficult to recall and even recognize.  Memory can be a fleeting capability and capabilities vary based on the subject matter.  For example some old professional information and new relating information may be normal while, new skills unrelated to the old information may find no anchor point in memory and be unusually difficult to retain. 

TEST:  Give a short story and ask a detail about a fact in the story.



Receptive Language - understanding spoken or written language processing can be slow or broken, word finding difficult or error prone.  Reading multi-line single space, 1.5 space or sometimes even double space may be difficult because attention jumps all over the page and can't track.  Listening to speech and taking in the non-verbal communication at the same time may be too much for the brain to process at once.

I once had my brain seize when some one I was talking to whipped around quickly and enthusiastically agreed with me.  I lost so much processing power - I nearly lost my balance and fell to the ground.  I had barely a concept of the thing I was leaning on for support (a table).  I couldn't remember my purpose or the name of the person I was talking to (which was very very important to me).  It took me several awkward minutes to recover my ability to speak and when I did I couldn't remember important questions I had brought to the conversation for at least a half hour.


TEST:  Have the pt read a paragraph and respond with what they comprehended.

TEST:  Tell a story.  Ask the patient for their most detailed comprehension.

TEST:  Does comprehension diminish if eye contact is demanded?



Expressive Language - difficulty using language spoken or written language.  Speech difficulties may include odd pauses, word finding difficulties (including using a word which is opposite or sounds like the intended word), not remembering what they are saying to the degree of being unsure they are making any sense, typing errors such as using "c" for "k" or other subtle language mistakes not usually made.  Awareness of this symptom varies from being completely unaware to frustration over "not being able to communicate".  Encouraging pts take more time to express themselves might help over ride a "need to rush" symptom also associated with lyme.  For some lyme suffers, cognitive dysfunctions manifest in a complex similar to being "locked in" - able to walk and talk, but not communicate what they intend.

I, and others with lyme,  have experienced unexpected question as akin to being asked "Tell me everything you know.".  Clearly its an impossible task.    Responses tend to make sense but have more to do with "the closest thing my brain could 'see' " rather than any consistency with intention or belief.  The experience feels somewhat like throwing a beach ball on a fire to put out a fire, in a confusion:  the beach ball was the first identifiable item; there was an urgent need for response. It was impossible to see what was "beyond" the beach ball,
and the beach ball was applied. Similarly, this response may seem unreasonable, but within normal perameters.

Yes and No Questions -
Lyme can leave much uncommunicated.   Words "on the tip of the tounge" is a phenomena with which we are all familiar.  Lyme can produce a similar effect with whole concepts and linear thinking.  Whole dialogs can be thought but spoken.  This is part of the "locked in" experience.  Somehow, starting the subject off helps break this "spell" a bit and help the pt get their thoughts to expression.  This does requires a higher level of work, attention, persistence, compassion and intuition from the physician and there is a risk of an undesired leading of the patient.  Focus should be on only "starting" the patient off, but offering suggestions as long as "something seems off" with the patient's demeanor.

TEST:  Name as many words as you can describing one object such as "cat".

TEST:  Without offering your own understanding ask "Is this what you intended to tell me?"  If a patient responds to this question with "What (are you referring to)?"  Avoid offering your own understanding and ask if they remember what they just said.



Visuospatial Processing - making accurate conceptualization of visual space and relations of objects in space

TEST:  Watch pt go up and down a flight of stairs.  Ask them to turn around 1/2 if its not too dangerous.


 

Abstract Reasoning - difficulty with decision making, problem solving and planning

 TEST:  Fibonacci sequence exercises can reveal working memory problems quite sharply in people of all intelligence levels, because it requires numbers to stay in memory to execute the task.



Mental and Motor Processing Speed - difficult keeping up with conversation, moving through space and keeping an accurate idea of time.  Deadlines may start being missed.

TEST:  Ask what time is it and use a clock with hands and a then a digital clock.

TEST:  Ask if there is an every day task which has become difficult.  Ask them to mimic the movements of this task and ask if there is premature fatigue or pain while doing the task.

TEST:  Ask pt to tap a finger continuously for 30 seconds to a minute.  The dominant hand should sound faster.


- reference:  Rissenberg, Marian & Chambers, Susan. "Cognitive Impairment in Lyme Disease: Specific functions an the impact of deficits", presentation at the American Psychiatric Association, May 1996




If something feels off, it is...

Whether its the physician, patient or significant other noticing something off, consider lyme if the unusual falls into categories of:

balance problems                  (I'm bumping into things a lot...)

timing problems                     (I can't throw a ball, tool, etc like I used to...)

problem solving difficulty     (It takes me forever to....)

long lapses between words            (the patient might even look frustrated...)

brain blitzes                                (Concepts of the every day are lost - "what is a table")




Other Questions which can start to reveal the hidden:

Who does the bills?  How long does it take?

Add 5 three digit numbers together.

Do you have difficulty dialing a phone?  - watch while the person executes the task.

Do you have difficulty driving?  Do you have difficulty know if it is safe to drive into an intersection?

Who does the cooking?  Is there a change in who does the cooking or the ability to cook? 





Ruling out lyme..

Lyme is a CLINICAL diagnosis according to the CDC.  No test western blot, ELISA or more sophisticated tests rules out lyme alone.  Unfortunately, finding lyme is ultimately based on judgement... if you don't trust your's, call in an expert.