福島県立医科大学 学術機関リポジトリ

Title

Differential diagnosis of memory impairment in areas affectedby a natural disaster: a case report

Author(s)Miyagawa, Akemi; Kunii, Yasuto; Gotoh, Daisuke; Ito,
Masashi; Itagaki, Shuntaro; Matsumoto, Takatomo; Kumakura,
Tetsuo; Yabe, Hirooki

Citation

Fukushima Journal of Medical Science. 67(1): 38-44

Issue Date

2021

URL

http://ir.fmu.ac.jp/dspace/handle/123456789/1383

Rights© 2021 The Fukushima Society of Medical Science. This
article is licensed under a Creative Commons [AttributionNonCommercial-ShareAlike 4.0 International] license.

DOI

10.5387/fms.2020-13

Text Version publisher

This document is downloaded at: 2024-10-16T12:58:02Z

Fukushima Medical University

A. Miyagawa
et al.


38Fukushima J. Med. Sci.,
Vol. 67, No. 1, 2021

[Case report]

Differential diagnosis of memory impairment in areas affectedby a natural disaster : a case report
Akemi Miyagawa1)2), Yasuto Kunii3)4), Daisuke Gotoh3), Masashi Ito3), Shuntaro Itagaki3),
Takatomo Matsumoto3), Tetsuo Kumakura2) and Hirooki Yabe3)
1)

Department of Disaster and Comprehensive Medicine, Fukushima Medical University, Fukushima
City, Fukushima, Japan, 2)Hibarigaoka Hospital, Minamisoma City, Fukushima, Japan, 3)Department of
Neuropsychiatry, School of Medicine, Fukushima Medical University, Fukushima City, Fukushima, Japan, 4)Department of Disaster Psychiatry, International Research Institute of Disaster Science, Tohoku
University, Sendai City, Miyagi, Japan(Received June 25, 2020, accepted February 16, 2021)
Abstract
We treated a man with a chief complaint of memory impairment after the Great East Japan Earthquake. Initially, he was diagnosed with dementia. However, after several tests, neither could adefinitive diagnosis of dementia be reached, nor was there any apparent evidence for depression, epilepsy, delirium, or internal medicine diseases. During the earthquake, the patient experienced thesevere trauma of watching his wife being swept away by a tsunami. Furthermore, he experienced
separation from his family. Because of this traumatic experience, we suspected that dissociative
disorder was involved in the development of the memory impairment and thus, we switched totreatments focusing on emotional support. Subsequently, the patient’s memory impairment gradually improved. The present case demonstrates the importance of considering dissociative disorders
when examining a patient with memory impairment in areas affected by disasters.
Key words : trauma, dissociative disorder, Great East Japan Earthquake, dementia

verely traumatic experience during the disaster, andwho, after returning home, presented with severe
memory impairment, which improved slowly. By
examining this case, we hope to highlight possibilities for the differential diagnosis of elderly individuals presenting with memory impairment in disasteraffected areas. Written informed consent wasprovided by the patient for the publication of thiscase report. At our institutions, case reports are
exempted from the need for approval from an ethics
committee.

Introduction
The complex disasters that occurred on or after
March 11, 2011—the Great East Japan Earthquake,the tsunami it caused, and the accident at the Fukushima Daiichi Nuclear Power Plant (FDNPP)—
caused coastline residents of Fukushima Prefecture
a great amount of psychological distress1,2). Of theresidents that were forced to evacuate due to the accident at FDNPP, many who returned to their homes
were elderly individuals3). When elderly individuals complain of memory impairment, we must consider dementia, delirium, depression, epilepsy onset,
cognitive impairment due to various diseases of internal medicine, and, in disaster-affected areas inparticular, dissociative disorder. Herein, we report
the case of a 69-year-old male who underwent a se-

Case report
After dropping out of high school, the patientbegan working in the construction industry, marriedin his 20s, and raised three children. He had a his-

Corresponding author : Akemi Miyagawa   E-mail : a-miya@fmu.ac.jp©2021 The Fukushima Society of Medical Science. This article is licensed under a Creative Commons [Attribution-NonCommercial-ShareAlike 4.0 International] license.
https://creativecommons.org/licenses/by-nc-sa/4.0/38

Memory impairment diagnosis post-trauma

tory of gastric ulcers and otitis media and had beenprescribed amlodipine for hypertension prior to his
first visit to our hospital. He had no previous history of mental illness.
On March 11, 2011, the patient witnessed hiswife being swept away in front of him by the tsunami
resulting from the Great East Japan Earthquake.
Following the accident at the FDNPP, he evacuatedwith his family and returned to his hometown 1 year
later. For 2 years after returning to his hometown,
he lived with his father and his son’s family while
taking care of his father. After living with his son’sfamily for more than 1 year after placing his father ina nursing home, he began to frequently lose valuable
items. He began to suspect that his son had stolen
them, and this issue eventually caused the son andhis family to move out. Afterwards, his memory
impairment gradually worsened, and he became unable to recall what he had done on any given day.
As his son was worried, he was brought by his son
to our hospital 1 year after separation. Until then,he had been visiting other internal medicine clinics
throughout the previous 2 years, but no particularabnormalities other than hypertension were pointed
out. During the first visit, the patient had no serious feelings about his memory loss. He went out
almost every day to interact with his acquaintancesand returned home without getting lost, but he could
not report how he spent the day. He was able tocontact his friends using his mobile phone and droveon his own without any trouble or traffic violations.
He denied having any depressive feelings, and no
obvious weight loss was observed. When we asked
if he got lost when he went out, he gave an unrelated
answer : “I’m going to see the sea.” He was alsoable to recount in detail how his wife was swept
away by the tsunami. During testing, the patientscored 16 on the Revised Hasegawa Dementia Scale(HDS-R), indicating a decline in cognitive function.
Additionally, computed tomography (CT) showedfindings of suspected dilatation of the lower horn of
the right lateral ventricle (Figure 1). From thesefindings, he was diagnosed with Alzheimer’s disease
and prescribed donepezil. However, compliance
was problematic due to his memory impairment.
He went to the hospital once every 2 weeks ; 4months on, in November 20XX, after a very emotional fight with his son, he reported this fight with
substantial details that were confirmed by the caremanager. Two weeks later, he was able to reportwhat happened without any error or misremembrance. Furthermore, in December 20XX, he remembered exactly what he was shopping for. In

39

Figure 1. Brain computed tomography findings at thefirst visit. Dilatation of the lower horn of theright lateral ventricle was suspected.

addition, he recalled correctly about the contents ofthe examinations that he took 2 weeks prior. We
thought that the patient’s state changed from that ofhis first visit. Blood tests showed no evidence ofanemia, hypoproteinemia, thyroid dysfunction, liver
and renal dysfunction, or abnormal glucose metabolism. Although a Mini-Mental State Examination(MMSE) performed at this time showed 23 points,
and delayed recall of 0 points, we thought memory
impairment was tending to improve clinically. As
this course was not typical for dementia, the patient
was admitted to the Department of Psychiatry at Fukushima Medical University for more detailed testing.
During the first week after admission, the patient was relatively calm throughout the day, butwould often become irritable after sunset. However, by the second week, he had calmed down and
was able to appropriately interact with staff and other inpatients. He said at the interview that he had
been heading to the sea when he regained control of
his mental faculties. Cranial magnetic resonanceimaging (MRI) revealed no cortical atrophy (Figure2). A slight left-right asymmetry in the hippocampus was observed (Figure 3), but upon interpretationof these images by a radiologist, no particular abnormality was diagnosed (Figure 3). In addition, there
were no high-intensity regions observed in the hippocampal region. In a dopamine transporter (DaT)
scan, the specific binding ratios of the nigrostriatal
pathway were 3.77 on the right and 3.86 on the left,
which indicated a slight reduction relative to normal

40

A. Miyagawa et al.

Figure 2. Brain magnetic resonance imaging findings(horizontal section). Cerebral cortex atrophy was
not noted. There were no findings of high intensity in the hippocampus region, nor were there
findings suggesting ischemia in the DWI.

Figure 3. Brain magnetic resonance imaging findings(coronal section). There was a difference in hippocampal size on the left and right, but no abnormality was noted by the radiologist. We ultimately determined this finding to have little pathologicalsignificance.

values ; however, the radiologist interpreted thesefindings as having no significant abnormality. Ultimately, we determined that these MRI findings
showed few pathological signs. In the electroencephalogram (EEG), α activity of 9-11 Hz and 30-80
μV were observed and there were no abnormal find-ings, including slow-wave.
In the Baum test, a drawing of a tree reminded
him of the damage he suffered due to the tsunami
and the loss of his wife ; he became quite emotional
and the test had to be suspended. The Wechsler
Adult Intelligence Scale (WAIS-III) revealed a fullscale intelligence quotient (IQ) of 81, a verbal IQ of
80, and a performance IQ of 87, all of which were
within normal ranges. The patient produced manyerrors on the Benton Visual Retention Test, suggesting a decline in cognitive function. However,as no obvious abnormalities were observed in theimaging studies, we could not positively diagnose
him with dementia. Similarly, as EEG and blood
analyses revealed no abnormalities, the possibility ofcognitive decline due to epilepsy, delirium, or otherphysical diseases was considered low. As his daily
activity remained normal and he felt no depressive
mood, the possibility of memory impairment due todepression was low. Overall, as he had serious
psychological trauma and his experiences of separation from his father and his son’s family affected him
as further trauma, we considered that he sufferedfrom continuing dissociation, resulting in memory
impairment.
Therefore, we changed the treatment strategy
from drug treatment and life support for dementia to
focusing on creating a living environment that was
supportive, comfortable, and felt at ease. Because
the patient’s relationship with his son was strained,
we had nurses and support service providers assist
the patient with daily tasks (e.g. cooking, cleaning,
and taking medicine). Before beginning treatment,
the patient spent the entirety of every day outside of
the house and was unable to turn off the lights atnight. We thought that he might be feeling anxious
or nervous and began treating him with sertraline(25 mg daily) in May 20XX+1. Very quickly, he began to spend less time outside, started turning off
the lights when going to sleep, and was able to remain calm while speaking about his wife. He would
also sometimes spend time at senior care facility andbegan to look forward to the activities planned there.
However, once his sertraline dose reached 100 mg/
day in June 20XX+1, he began to spend money extravagantly, and we suspected that he was experiencing drug-induced hypomania. We were, therefore, forced to terminate the sertraline treatment
after a total of 3 months. After terminating drug
treatment, the patient’s tendency to frequently leave
the house did not return. He said that he could remember better than before. The patient washoused in a residential complex constructed forMemory impairment diagnosis post-trauma
Table 1.
Examination time
Cognitive test
HDS-R

41

Cognitive scores over time.

Initial visit

4 months
later

16

MMSE

23

13 months
later

17 months
later

22

21

24

26

Abbreviations : HDS-R, Revised Hasegawa Dementia Scale ; MMSE, Mini-Mental State Examination

evacuees from the nuclear disaster at Fukushima,and he began to actively interact with others who
were in similar circumstances. He was tenderly
cared for by the other residents of this community,and his memory impairment improved gradually.
Approximately 9 months after discharge, although
delayed recall was at 2 points, the total MMSE score
improved to 26, which is within the normal range(Table 1).

Discussion
The Pacific coastal area of Fukushima Prefecture that was affected by the Great East Japan Earthquake was home to communities of elderly people
before the disaster occurred3). Therefore, it is believed that, even now, there are elderly individuals
bearing various of disaster-related traumatic experiences in the area. When elderly individuals fromdisaster-affected areas complain of memory impairment, there are many possible diagnoses besides dementia, including depression, delirium, epilepsy,
various physical illness that causes memory impairment, and dissociative disorder.
This patient had no particular abnormalities
during his visit to the internal medicine clinic, andblood tests at our hospital showed no abnormalities
in thyroid, liver, or kidney function. We did not
check vitamin or folic acid levels in his blood, but he
did not exhibit hypoproteinemia or reduction in his
body weight. Hence, the possibility of cognitive
impairment due to deficits in vitamins or folic acidwas not high.
While he was admitted, he experienced moodswings between morning and evening over thecourse of a single day. However, there was never a
clear relationship between his mood swings andmemory impairment. Further, in the tests conducted while he was admitted, α-waves appeared
normal and no epileptic waves were found on EEG,
even when his memory impairment was severe.
We did not find any evidence suggesting low consciousness. Therefore, both delirium and epilepsy
were unlikely explanations for his memory impair-ment.
In elderly individuals, depression does not manifest as a change in mood ; rather, it usually involves
unexplained general physical malaise, issues withconcentration, and memory impairment4). Because
we opted to treat this patient with sertraline after
discharge, his inability to calm down soon recovered,and he was able to recount stories of his wife without becoming emotional. Thus, we can surmisethat he had been suffering from anxiety, frustration,and irritation, suggesting underlying depression.
While it is generally recommended that as long asside effects are not a problem, antidepressantsshould be continued at the same dose employed during the acute period for at least 4-9 months after remission5), we were only able to administer sertraline
for approximately 3 months. However, because thepatient’s MMSE and HDS - R scores slowly improved, even after the discontinuation of sertraline,
it is unlikely that the improvement in the patient’s
memory impairment was due to the treatment of depression by sertraline. Additionally, the patient
proactively left his house and often interacted withfriends, indicating no issues with his motivation or
activity levels. Given this course, depression was
also an unlikely possibility.
In Japan, the HDS-R is a well-known screening
test for dementia, similar to the MMSE. Together,
the two have a Cronbach’s α of 0.90, and a correlation coefficient of 0.94, indicating a high degree ofcorrelation6). While the sensitivity of the MMSE is
81% and its specificity is 89%7), the HDS-R has asensitivity and specificity of 90% and 82%, respectively8), and is relatively unaffected by education level9) ; thus, it is a very useful tool for diagnosing dementia. For this reason, the fact that the patient
had a low HDS-R score at the first examination allows us to assume that his MMSE score was also
low.
We initially began treatment for dementia dueto the patient’s low score on the delayed recall task
at his initial evaluation. As there were also a highnumber of errors on the Benton Visual Retention
Test administered during hospitalization, we further

42

A. Miyagawa et al.

suspected some kind of decline in cognitive function.
In the ICD-10, dementia (F00-F03) is described
as a syndrome resulting from neuropathology, which
is usually chronic or progressive, features disordersof multiple higher cortical functions, and is not accompanied by disturbance of consciousness10). As
it is an organic brain disease, diagnostic imaging often shows abnormalities and slow waves are often
detected on EEG beginning in the early stages11).
This patient was able to interact with his acquaintances via mobile phone. He could drive withoutcommitting traffic violations. Although his relationship with his son was deteriorating, he displayed nosocially deviant behaviors, and his higher cortical
function on the whole did not seem to be declining.
Further, while it appeared that his forgetfulness had
progressed from symptom onset to his first visit
with us, there were several episodes suggesting that
his memory disorder had improved since his first
visit. For example, approximately 4 months after
his first visit, he was able to correctly report the details of his troubles with his son, and he could accurately talk about the tests and instructions he hadreceived 2 weeks previously. Thus, his condition
did not align with the definition of chronic and progressive cognitive deterioration. Initial imaging
tests showed findings suggesting enlargement of theinferior horn of the right lateral ventricle and thiswas similarly suggested by the head MRI performed
after hospitalization, but a radiologist did not find it
to be abnormal and it was ultimately determined tohave little pathological significance. Further, there
were no high-intensity findings suggesting sclerosis
or ischemia in the hippocampus on head MRI.
Moreover, after the patient’s father was institutionalized, it was several months before his relationship with his son began to deteriorate due to delusional accusations of theft. Thus, the symptoms
seemed to progress too quickly to consider a diagnosis of dementia. Combining the above findings, thepossibility of dementia could not be ruled out, butalso could not be actively supported. Further, transient global amnesia (TGA) was ruled out because
there were no findings suggesting hippocampal sclerosis or ischemia, and because TGA usually resolves
within 24 hours.
It has been reported that during disaster-related events, elderly individuals are more likely than
younger individuals to develop post-traumatic stressdisorder (PTSD) and adjustment-related disorders,rather than depression12). There are also reports
indicating that it is possible for PTSD to occur due
to illness or the death of a loved one13,14). While

this patient had a severely traumatic experience, he
did not present with particularly severe memory impairment while living with his family. However, after his father was placed in a nursing home, he began to experience memory impairment, and after his
son’s family moved out of his home, his symptoms
worsened to a level where he could not remember
what he had been doing that day. However, as
mentioned above, his memory impairment showed atendency to improve in the course of his outpatient
period, and as no imaging or EEG abnormalities
were observed, we considered the possibility of dissociative disorder.
Dissociative amnesia, grouped among dissociative disorders, is a form of retrograde amnesia,
which often appears as impaired recall for a specifictraumatic event. As such, it was ruled out for thispatient. Dissociative stupor was also excluded, as
the patient was able to hold normal conversations
and drive, even if he could not recall those events.
Depersonalization most often arises under extreme stress and patients often complain of a loss of
their sense of reality, yet there were no such complaints in this case. However, there are several reports concerning depersonalization in which shortterm memory impairment is exhibited as a result ofa deficit in perception, attention, and concentration
toward new information15,16). When the patient was
asked at his first visit whether he gets lost whencoming home from an outing, he gave an unrelated
answer (that he goes to see the sea). He also stated that he sometimes heads to the sea before heeven realizes it. If these complaints are taken toreflect a decline in attention and concentration, it ispossible that the patient is exhibiting anterograde
amnesia as a result of persistent depersonalization
due to an inability to adapt to the severe stress of
witnessing his wife being swept away by a tsunami
and the additional stressors of beginning to live apartfrom his father and a deteriorating relationship withhis son.
This report does not rule out the possibility
that these symptoms are a result of dementia. In
fact, his improvement on the delayed recall task was
slow and he also had many errors on the Benton Visual Retention Test. Thus, the patient’s symptoms
are not explained by a dissociative disorder alone.
However, that the patient’s memory disorderimproved—although not completely—after he began
to receive emotional support also suggests that psychological stress was involved in the memory disorder in this case. It is thus vital to recognize that if
dissociative disorders had not been considered as a

Memory impairment diagnosis post-trauma

potential cause of this patient’s symptoms, intervention would not have focused on emotional supportand improvement in cognitive function would likely
not have been achieved as it was here.

2.

Conclusion
Even when the course is not typical of dementia, memory disorder in older adults might be diagnosed as dementia only, and if interventions are notreassessed, opportunities for symptomatic improvement may be lost.
It is vital to bear in mind the possibility of dissociation when examining older adults complainingof memory disorder, particularly in areas that havebeen struck by disaster.

3.

4.

5.

Abbreviations
CT, computed tomography ; DaT, dopaminetransporter ; EEG, electroencephalogram ; FDNPP,
Fukushima Daiichi Nuclear Power Plant ; HDS-R,
Hasegawa Dementia Scale ; ICD-10, International
Classification of Diseases, 10th Revision ; IQ, intelligence quotient ; MMSE, Mini-Mental State Examination ; MRI, magnetic resonance imaging ; PTSD,
post- traumatic stress disorder ; WAIS, Wechsler
Adult Intelligence Scale ; TGA, transient global amnesia.

6.

7.

8.

Conflict of interest
The authors report no conflicts of interest in
this work.

9.

Ethics approval and informed consent
At our institutions, case reports are exemptedfrom the need for approval from an ethics committee. Written informed consent was provided by thepatient for the publication of this case report.

Consent for publication

10.

11.

Written informed consent was provided by thepatient for the publication of this case report.
12.

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