What is the best way of assessing neurocognitive dysfunction in patients with primary hyperparathyroidism?

ABSTRACT

CONTEXT The patient attending with asymptomatic primary hyperparathyroidism (PHPT) is a common occurrence in the outpatient endocrine setting. Indeed, more than 80% of contemporary PHPT patients are considered asymptomatic at diagnosis. A frequent question in clinical practice is at what stage may the patient be offered curative surgery. This may well relate to the duration and the degree of hypercalcemia, evidence of end-organ effects, and whether clear symptoms may or may not be attributable to the underlying condition. OBJECTIVE: There are well-recognized psychological and cognitive changes that can occur in the context of PHPT. A challenge for the clinician is to discern to what extent these symptoms may be present (often very close questioning is required) and how to measure and categorize them. INTERVENTIONS: Assessment can be difficult because patients who have PHPT tend to be more elderly, and they often have other overlapping comorbidities that may cloud the diagnosis. A decision then has to made as to whether such symptoms are likely to be a result of prolonged hypercalcemia, to what extent they can be attributed to the underlying disease, and whether they constitute sufficient weight to warrant surgical intervention in an otherwise "asymptomatic" patient. Practice tends to vary, and some clinicians may undertake watchful waiting or conservative management, whereas others may more readily push for surgical parathyroidectomy as a definitive treatment. We reviewed the literature on the subject of neuropsychological testing in the management of PHPT. POSITIONS A controversy in clinical endocrinology is how to assess the cognitive, quality of life, and psychological effects of hypercalcemia. Multiple tools are being used, and significant changes have often been demonstrated in such parameters after parathyroidectomy. CONCLUSIONS: We reviewed the latest studies on this subject and assessed the usefulness and validity of such tools in clinical practice, identifying several scores and measures that have been validated in clinical practice; comparisons are made with similar assessments such as the Adult Growth Hormone Deficiency Assessment questionnaire.