Donezepil, an acetylcholinesterase inhibitor, has been a standard of pharmacological treatment for years in the treatment and management of mild cognitive impairment and various dementia. Little is known about its utilization to benefit persons with chronic subdural hematoma (SDH) and cognitive impairment. RM is a 53-year-old eighth grade educated Latin American male with a history of chronic SDH due to traumatic brain injury. The initial injury resulted from a motor vehicle accident in 1985 and he had frequent headaches since then. In January 2000, he was diagnosed with SDH. After a neurosurgical evaluation, conservative management was chosen. In the last 5 years, he experienced mild cognitive deficits that have progressed to severe memory loss, visuo-spatial difficulty and neuropsychiatric changes. His wife frequently noted, “when shopping in grocery stores he cannot remember where he is, he forgets to lock the door at night and frequently got lost when he went out alone”. Neuropsychiatric changes occurred, including depression, insomnia and psychotic features, such as hallucinations and paranoia. In September 2002, he was evaluated and scored a 17/30 on Mini Mental State Exam (MMSE). His Functional Activity Questionnaire (FAQ) revealed a score of 23/30. In terms of cognitive activities of daily living (ADL) he was unable to write checks, shop alone, play a game of skill, discuss current events, remember appointments or drive without getting lost. He required minimal assistance in his self-maintenance ADLs such as bathing and dressing. Neuropsychological testing revealed his fund of general knowledge to be moderately impaired for his educational level, with impaired stream and content of thought. Remote, recent and immediate memory was not intact. Brain MRI scans revealed no further subdural hematoma in June 2000, which showed encephalomalacia involving in the previous SDH region. Electroencephalogram showed 7-8 Hz of rhythmic activity without epileptiform activity. He was placed on donepezil 5 mg and increased to 10 mg daily since September 2002 for his memory loss and impaired ADL's. During his visit in January 2003, his MMSE increased to 23/30, with improvements in orientation, calculation and copying offset by diminished recall capacity. His FAQ score subtly improved to 21/30. In his ADLs, he was able to converse and discuss news events with less memory difficulty. He was independent in his self-maintenance activities. At this visit, his wife observed he appeared “to be less forgetful than he had been and more of the RM she remembered from previous years”. The other neuropsychiatric features, such as hallucinations and paranoia also became less frequent. In conclusion, donepezil was used in this patient with SDH over the course of 4 months and there was measurable improvement in his cognitive capacity, psychosis, and ADL’s by MMSE and FAQ score and most importantly by family’s observation.
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