A 63-yr-old woman with a history of steroid-dependent rheumatoid arthritis and major depressive disorder was admitted to the rehabilitation unit 5 days after a left hip arthroplasty revision. Clinically, she appeared older than her chronological age, her mannerisms were slow, and her voice was low. Her progress in rehabilitation was slower than expected. Thyroid hormone levels were obtained as her presentation was consistent with hypothyroidism. Her plasma thyroid stimulating hormone level was 33.8 ml unit/liter (normal, 0.3–5.0 ml unit/liter) and her thyroxine level was undetectable. She was started on thyroid replacement therapy. In addition to her orthopedic rehabilitation, a brief neuropsychological assessment was completed that included the Repeatable Battery for the Assessment of Neuropsychological Status to document current cognitive status.
The Repeatable Battery for the Assessment of Neuropsychological Status total scale score was at the third percentile. Her premorbid intellectual ability was estimated to have been at the 90th percentile based on educational attainment. One year later, comprehensive neuropsychological reassessment was completed. These test results demonstrated the reversal of cognitive deficits as exemplified by attainment of a Wechsler Adult Intelligence Scale III Full Scale IQ Score of 113 (81st percentile). In addition, her depression resolved as evidenced by obtaining a normal score on the Beck Depression Inventory.
This case illustrates the importance of screening for common metabolic abnormalities when rehabilitation is not progressing as anticipated.1,2 This case also highlights the profound cognitive and affective impairments that can occur with hypothyroidism and the dramatic reversal of these impairments that are possible with appropriate medical therapy (Fig. 1).
1. Dugbartey AT: Neurocognitive aspects of hypothyroidism. Arch Intern Med
2. Osterweil D, Syndulko K, Cohen SN, et al: Cognitive function in non-demented older adults with hypothyroidism. J Am Geriatr Soc