Question: My stepmother has been diagnosed with metabolic encephalopathy. She fell at home (she has lived independently most of her life with no problems that we know of, except for a general decline in weakness that the family has noted since maybe December but no other real cognitive deficits--she's always been a "prickly" person) and at the hospital they checked her out and physically she was fine except she couldn't walk. Her mental condition had deteriorated considerably, as if she had a stroke (I think I witnessed her having a TIA in the emergency room!). Naturally, she was confused. After five days running tests, they came up with nothing physical and she was sent to a nursing home for recovery. Nine day later she fell and went back to the hospital. This time we asked for a full neurological workup and for a psychiatrist to visit (I'd thought for a while that she might be depressed). The neurologist concluded that she had "rapidly progressing dementia" after an EEG and a visit. The psychiatrist put her on Remeron to improve her appetite. She has been back at the nursing home for about 10 days now and we've been told that she has metabolic encephalopathy and her cognitive function is "severe" and they've noticed a significant decline since she returned from the hospital. The patient is 79 and has had very poor eating appetites for at least 30 years. She dropped 20 lbs in less than two months. She has gained 6 lbs after returning to the nursing home, she is now starting to ambulate, her long-term memory has mostly returned and her short-term memory is very iffy. The social worker told us that her executive functioning is about shot because of her impulsivity (e.g., trying to get off an exercise bike and move to the wheelchair without even realizing the bike had to be stopped before she could move). They say she needs a lot of verbal cues. When I talk to her, however, we've been able to get through some of her serious concerns, but we haven't addressed her mental confusion except to keep telling her that she needs to eat and hydrate. Am I missing something? There doesn't appear to be any underlying cause.

Her current medications:
Acetaminophen 325 mg/every six hours as needed (barely used)
Alendronate sodium tablet 70 mg/1 time per day
Aspirin tablet 81 mg/1 time per day
Altenolol tablet 25 mg/1 time per day
Azelasitine HCI 5% two times/day for allergy
Calcium carbonate--Vitamin D3 tablet 600-400 mg-unit, 1 time per day
Calmsoeptine Ointment, as needed
Colaca capsule 100 mg/two times per day (not always needed)
Enoxaparin sodium solution, inject 30 mg subcutaneously at bedtime
Lisinopril table 10 mg/2 times per day. This was doubled to 20 at the last hospital visit because her blood pressure was so high. Blood pressure has been good since.
Mirtrazpine 7.5 mg, nightly
Sennosides capsule 8.6 mg, as needed for bowel regimen

OK, so we have two different diagnoses: rapidly progressing dementia from the hospital neurologist and metabolic encephalophathy (which should have an underlying cause) from the nursing home. I would tend to believe the hospital neurologist over the nursing home, but I want to keep looking because if it is the other, maybe something can be done.

As far as I know, and I will double check, all the tests you suggested have been conducted and were normal. She had a small spike of calcium in her blood, but that was corrected with hydration.

I also forgot to add that she has osteoporosis and is a breast cancer survivor of many years and recently has been tested. Results were fine. She had a complete bone scan as well while she was in the hospital, which the oncologist had asked for, too.

I found her last oncologist visit report and it states that in Feb 2018: Incidental finding of 1.8 cm hypointense focus at T1 vertebral body on MRI performed for an unrelated reasons. She was also found to have an igG monoclonal protein spike in her serum and free lambda and free lambda light chains in her urine both felt to be an MGUS. Oncologist recommended a skeletal survey with the comment "the patient would like to put this off until she sees me in 4 months." She hasn't had that survey yet.

So, I need to talk again to the oncologist, the new neurologist that's seeing her in the nursing home, and once again speak to her personal PCP? His reaction after her first hospital visit was that this was NOT the woman he's known for 15 years and he'd seen her as recently as March 2018. He's the one who asked for the full neurological workup.

Thank you



As a family, we've noticed some strangeness since around Christmas and more so after Valentine's Day. I'm only discovering now how isolated she has kept herself, cancelling appointments, not answering her phone or leaving her house, bad hygiene, etc.

Thank you very much for your help. I greatly appreciate it. My stepmother has had multiple MRIs recently so we have that covered.

Thank you very much, Dr. Spaho. Your insight is greatly appreciated.