The Bingo Card Sign as an Early Symptom of Alzheimer’s Disease
Cassandra L.A. Hawco1, Donald F. Weaver1,2
1Krembil Research Institute, University Health Network,
2Department of Medicine, Division of Neurology, University of Toronto
Alzheimer’s disease (AD) is characterized pathologically by irreversible protein misfolding-induced neuronal loss, and clinically by progressive impairments in memory, judgment, decision making, literacy and numeracy. We report a patient referred to Memory Clinic with a single complaint, “reduced capacity to play bingo.” We suggest that the capacity to successfully play bingo may afford clinical clues indicating an early symptom of dementia and inquiries about bingo participation may be a useful when assessing individuals for dementia. Bingo requires the use of multiple cognitive skills which are impaired by AD, including number recognition, letter recognition, short term memory and concentration. With the game of bingo steadily gaining in popularity it may become an easily utilized line of questioning to detect indications of dementia prior to the development of currently recognized clinical symptoms.
Introduction: Alzheimer’s disease (AD) is characterized clinically by progressive impairments in memory, judgment, decision making, literacy and numeracy1. At the time of clinical diagnosis, the individual has typically unknowingly experienced subtle deficits in neurocognitive function for multiple years2. The identification of new, reliable early symptoms with which to facilitate timely recognition of a dementing process, such as AD, would be a useful addition to the battery of questions used during assessment. In this report, we suggest that inquiries about the capacity to participate in bingo may be a useful line of questioning when assessing individuals for possible dementia.
Case Report: A 76-year-old female was referred to the Memory Clinic with a single complaint, “reduced capacity to play bingo.” Over the past decade, she had played bingo 2-3 times per week, playing 20 bingo cards simultaneously, “never missing a number”. In the two years prior to her presentation, she had progressively developed problems whilst attempting to play at this level, gradually reducing the number of cards played from 20 to 10; she had also noticed increasing confusion when trying to remember the numbers that had been announced and then recognize them on the cards. Her social group at the bingo-hall joked with her, commenting that other women who had demonstrated a declining capacity to play had gone on to be diagnosed with dementia. At initial presentation, she denied any other symptoms related to memory or cognitive function. She scored 27 on her Mini Mental Status Examination (MMSE), 26 on her Montreal Cognitive Assessment (MoCA), and made no errors in clock drawing. Her neurological examination was normal and imaging showed “mild atrophy in keeping with age”.
Over the ensuing three years, her ability to play bingo gradually dropped from 10 cards to 2, with her error rate in recognizing called numbers correspondingly increasing. She decreased her frequency of play to once per week. At this three year post-initial presentation time-point, her MoCA score was 20 and her MMSE was 22; she was now unable to complete her normal activities of daily living. She was diagnosed with probable AD.
Discussion: Questions regarding social pastimes can provide useful insights regarding cognitive and memory processing. In a study of 130 community-dwelling people with mild-moderate AD, 34% of participants experienced decreased engagement in leisure activities due to impaired performance3. Bingo, a game of chance in which players match the announcement of randomly drawn numbers against numbers that have been variously pre-printed on 5x5 matrix cards, is a social activity that may enable such insights. It has become increasingly popular across Western cultures, particularly amongst the elderly4,5.
The ability to participate in a bingo game may allow for the detection of indications of dementia prior to the development of currently recognized clinical symptoms. Bingo requires the use of multiple cognitive skills including, number recognition, letter recognition, short term memory and concentration6. People with minimal cognitive impairment (MCI) or early AD frequently experience difficulties with short term memory and concentration. They also require extended time to initiate and execute goal-directed hand movements and an overall general impairment of motor function7. Although impairment in the functioning of the visual system occurs with normal aging, such impairments are more apparent in people with AD, including reduced contrast sensitivity and difficulties in visual search tasks crucial to playing bingo3,8.
This case study suggests that the capacity to successfully play bingo may afford clinical clues indicating an early symptom of MCI or AD. Clinically, an initial complaint from the patient noting a decrease in their ability to play multiple simultaneous cards is suggestive of one or more cognitive impairment and warrants further investigation.
Dr. Donald Weaver, Krembil Research Institute, UHN, 60 Leonard Avenue, Rm 4KD477, Toronto, Ontario, Canada, M5T 2S8.
Conflict of Interest
The authors declare no conflicts of interest in the preparation or content of this manuscript.
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