Neurodevelopment was normal. She graduated from college and worked as a teacher before retirement at 60-years-old. There was no history of psychiatric symptoms or family history of psychiatric disorders or dementia.
A graphical timeline with the most relevant symptoms is shown in Figure 1.
Her present illness started with panic attacks at age 78, consisting of abrupt surges of intense emotional discomfort accompanied by abdominal distress (i.e., heartburn), shortness of breathing, chest discomfort (i.e., chest tightness), feelings of choking, and fear of dying or being seriously ill. The episodes, lasting around 1 h, were recurrent (3-4 per day) and were triggered by situations, such as waiting in line or seeing traffic. Flupentixol-Melitracen (21 mg/day) was prescribed but caused nervousness and hand trembling. The frequency of symptoms decreased with Sertraline (50 mg/day) and Mirtazapine (15 mg/day). At the end of that year, she developed parkinsonism (bradykinesia, hands tremble, hypophonia, and hypomimia), reported fluctuations in arousal (described as lethargic episodes), two episodes of syncope, marked constipation, and subjective decline in language and memory.
At the age of 80, cognitive decline and parkinsonism became prominent. Structural magnetic resonance image (MRI) showed diffuse brain atrophy with no vascular injury, leading to a misdiagnosis of possible Alzheimer's Disease treated with Donepezil. She ceased this medication because of heartburn and physical discomfort, to which rivastigmine transdermal patches were prescribed. After a few months, she was re-admitted due to increased parkinsonism and was again misdiagnosed, but with Parkinson's Disease. Levodopa + Benserazide was prescribed, causing significant improvement of tremor and hypomimia for less than one year.
During the 2 years before index admission, bradykinesia, hypophonia, and cognitive decline (in language and memory) gradually worsened. Panic attacks continued at a lower frequency (1 episode per day, 1 h each), and postprandial hypotension episodes (systolic blood pressure drop of 40 mmHg after eating) were also evidenced.