NEUROPSYCHOLOGICAL REASSESSMENT OF THREE N.Z. NURSES
Three cases (theatre nurses from the same hospital) who have been reassessed for on-going neuropsychological damage after long-term exposure to glutaraldehyde. (Reassessed for ACC, NZ by Dr Dorothy Gronwall.)
CASE 1: [Ex-theatre nurse working from the early ‘70s. Unprotected use of glutaraldehyde/formaldehyde until 1991 - open uncovered troughs. Plus the department also had an old-Xray machine off the plaster room. Considered sensitised in 1983 by doctor, with fatigue and ‘flu-like symptoms. 1991-1993 was in a new purpose built theatre with recycled/positive air pressure ventilation system. Multi-system problems developed rapidly. Finished work in December, 1993.]
First assessment: August 1994 (Mr Waddell). Second assessment: August 1995 (Mr Waddell): “Results were broadly similar” to those found in August 1994. “She demonstrated attentional deficits, reduced verbal memory , and slowed visuomotor reaction times.”
Third assessment: August 1996. (Dr Louise Smith):
“During the last year it would appear that her physical progress has reached a plateau. She reported that she is coping relatively well in the home setting and can complete tasks e.g. housework if she paces herself and intersperses activity with rest. She experiences bursts of energy which may last 30 mins. Her headaches have markedly reduced and she is sleeping better.
Underlying this improvement is the avoidance of specific food products and environments (e.g. where people are smoking) and close monitoring of fatigue levels. She and her husband have in fact made considerable adjustments to their lifestyle to accommodate her health problems. Exposure will still induce symptoms (eg sweating, loss of sensation in limbs, difficulty with balance) ...
With respect to cognition, confusion in working with numbers has continued as has the inability to identify colours consistently. The attention deficits have also remained (e.g. going into the wrong bank by mistake). The reduced tolerance for frustration continues to be a factor... Socially she has had to restrict her activity...
Her neuropsychological profile remains relatively stable...average to high level of intelligence. ..evidence of attentional deficits, impaired long-term visual memory, and visual-spatial/visuomotor memory. There has been some improvement in short-term memory for information which is verbally presented in that this is now only borderline...The gains which have been made appear to be mainly resultant from lifestyle adjustment ...should she be placed in a less controlled environment (e.g. a workplace) cognitive symptoms would intensify. Neuropsychological testing is no longer appropriate, unless a major change occurs and reassessment takes place in more than 5 years time.”
CASE 2 (Ex-theatre nurse): Assessed May 1996 (Dr L Smith): “...Tests indicated a reduction in non-verbal reasoning skills, impaired visuo-spatial skills, impaired verbal memory both short and long term, and mild impairment of long term visual memory.”
Assessed July, 1997 (Dr L Smith): “Her report on her functioning was essentially unchanged... She continues to forget to complete tasks, is easily distracted, will forget conversations, and cannot track conversations where several people are talking at once. Writing and word finding are still problematic. As at last assessment she has high fatigue levels and can tolerate approximately half a day of mild activity if she rests or sleeps in the afternoon... For example she knows that doing the groceries is a task which will tire her for the rest of the day, so she plans carefully when she goes. Socially she does make an effort to remain in contact with others...she gives one lecture every six weeks to students to help her feel “normal”. Case 2’s frustration with her reduced capacity for work was noted previously. This continues with her stating that she had expected that she would have made more progress. She feels guilty when she is not doing things and tends to compare herself with people her age deciding that she is “useless”. Her concern that others do not understand what has happened, has led to a tendency to hide her difficulties from other people. There are indications of the “boom-bust” cycle, whereby she takes any sign of improvement as an indication to increase her activity levels, and then subsequently pushes so hard that symptoms will re-emerge at an even higher level (e.g. will get headaches, perspire, feel somewhat disorientated.”
She herself stated that she felt little had changed in the last 14 months and the assessment results support this. Functionally she continues to display cognitive impairment, high levels of fatigue, and reduced tolerance for activity... Her verbal skills are in the normal range but are lower than would be expected given her premorbid history. There is evidence of lowered non-verbal skills, particularly with respect to visuo-motor reaction time. Scores on measures of visuospatial skills and the ability to shift attention between alternatives, remain impaired. Short-term verbal memory is impaired, with long-term verbal memory being borderline to impairment. Short-term visual memory is in the normal range, while long-term visual memory is lowered.
It has now been approximately 2˝ years since she finished work, and the neuropsychological test results have been stable for 14 months. It would be fair to say that Case 2 is not ready to consider even part-time work, and that this is most likely to be the situation for some time to come... A repeat neuropsychological assessment is not necessary unless at some point she notices an improvement ...”.
CASE 2 and CASE 3 (ex-theatre nurses)
Request by ACC for previous reports to be commented upon, 1 March 1998, of Dr Dorothy Gronwall:
“ ...fatigue and not MCS is the main factor in limiting return to work in both cases... Case 2 stopped work... in Dec 1994 after 27 years...
Possible factors: [After head injury, malingering and depression were ruled out]. “Chronic fatigue syndrome (CFS): Fatigue is Case 2’s major limiting factor... A review of the literature on neuro- psychological deficits in CFS shows a very different pattern of subjective and objective scores from those recorded by Case 2. In particular Moss-Morris et al note that there is no clear evidence of sensory or perceptual impairments in CFS, yet there was definite impairment of visual perception in this case. Thus the pattern of her test results and subjective complaints is entirely consistent with the history of many years exposure to glutaraldehyde in her work-place.
There are two issues...The first is that is would be difficult to argue that Case 2 and Case 3 did not have work-related problems which resulted in them having to stop nursing. This was the conclusion made in the two neuropsychological reports in both cases, and obviously a conclusion reached by ACC, since the claims were accepted.
“... why are they still not able to work, in other words why have they not recovered? I found the description of Case 2’s current state [see above] very compelling, because it is almost identical to the accounts I get from older people who have continued to have problems following traumatic brain injury. The “boom and bust” cycle is very common, particularly in high-achieving people who are well-motivated to return to productive employment. Both these ladies are said to find their inability to return to work aversive, and from the reports I would rate them as well-motivated to regain their independence.
As already noted, I was unable to find any definitive information on the time course of recovery from exposure to glutaraldehyde. However I cannot see any logical reason why this would be expected to differ from other kinds of central nervous system injury. There is ample evidence that in most cases fatigue is one of the major limiting factors. Given that they also continue to demonstrate unequivocal impairment on measures of cognitive function, ny conclusion has to be that neither has yet recovered fully from the effects of the exposure.”
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Three critical care nurses in New York were documented by Dr Adrienne Buffaloe: “The patients’ symptoms of neurotoxicity which included a decrease in short-term memory, word retrieval problems, and inability to concentrate improved during the course of their treatment and has continued to improve over the last 18 months. None of the three adults has achieved her baseline neurological functioning. One of the nurses had a brain SPECT scan performed before her arrrival at our centre and the scan showed hypoperfusion in multiple areas consistent with chronic solvent exposure....”[1]
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To add to the picture, Dr Kaye Kilburn, (Ralph Edgington Professor of Medicine, USC School of Medicine), wrote to a SNFTAAS member: “The toxicity of photographic processing goes up with speed which involves heating. More vapors are produced and escape into the room. The most toxic chemicals are the phenols [for] example hydroquinone... Phenols are particularly toxic to the peripheral nerves and brain when inhaled as aerosols and vapors. These are organic chemicals... A major question is, are you noting nervous system symptoms, diminished recall memory, concentration, forgetting procedures, dizziness, unstable balance, sleep disturbances, somnolence and headaches? If so, then the likelihood of phenol-hydroquinone toxicity increases. I have seen7 or 8 patients with diminished brain function from working indoors on “rapid processors”. I think both glutaraldehyde and hydroquinone are most important candidate chemicals” (15 Jan, 1999). His web site details many of the tests available: <URL: www.neuro-test.com>
Geof Care, Managing Director, Photosol, London, replies: “So far as phenols are concerned, three were detected by the HSE: hydroquinone, phenol itself and 2,6-bis(1,1-dimethylethyl)-4-methyl phenol, and all in trace amounts - by inference low ppb's or even ppt's. My paper in the Lancet (Care: Darkroom exposure to hydroquinone, Lancet, 47, 121, 1996) calculates a theoretical HQ saturation vapour concentration of 3ppb which ties in well; even this would be vastly reduced by ventilation. I personally would discount danger from this source unless bad ventilation & other adverse circumstances allowed developer aerosols to be breathed in. Phenol is a gelatin preservative and probably is a faint left-over after film coating that leaches out during processing. The third phenol is unknown to me but again its concentration is minute. In short, I really cannot envisage harm from them unless you were right on top of the solutions and the local exhaust ventilation (nowadays fitted as routine above the tanks) was not working.”
[1]Buffaloe Adrienne. Environmentally-induced asthma: three women and a baby. p6. Presentation to American Academy of Environmental Medicine. Baltimore, Nov 7 1998.
