CASE 32
An 83-year-old woman is brought to the clinic by her husband who was concerned with his wife’s memory problems. He first noticed some memory decline a few years ago, butthe onset was subtle and did not interfere with her day-to-day activities. Mainly, she has some difficulty remembering details, is repeating things, and is being forgetful. The patient’s family noticed her gradually increasing memory problems, particularly over the past year. She is unable to remember her appointments and relies heavily on written notes and appointment books. Recently, she got lost while driving and was found by her family 10 hours later. She was unable to use her cell phone and was unsure about her home address and phone number. She has also become more reclusive. She does not enjoy her church activities anymore and prefers to stay at home most of the time. She does not want to cook, and she is less attentive to her housework. The patient says thatshe has always been forgetful. Her medical history is significant for well-controlled hypertension and a history of mastectomy secondary to breast cancer diagnosed 20 years ago. She has no significant history of tobacco or alcohol use. She is independent with all activities of daily living, but needs assistance with medication administration, banking, and transportation. She is up-to-date with her health maintenance and immunization. Her vital signs and general physical examination are normal. What is the most likely diagnosis? What office testing can help to determine a diagnosis? What laboratory testing and imaging studies are indicated at this time?
ANSWERS TO CASE 32:Dementia
Summary:
An 83-year-old woman is noted by her family to have increasing memory difficulties at home. She is forgetful, repeats questions, and does not remember conversations. She had the very significant episode of getting lost in her home town. She is seemingly unaware that there is a problem that is slowly and progressively worsening.
Most likely diagnosis:
Dementia of Alzheimer type.
Office-based testing that may be beneficial:
Folstein Mini Mental Status Examination (MMSE) is the most widely used instrument. Others available includethe Clock Test, the Short Portable Mental Status Questionnaire, the Mini-Cog Test, and the Montreal Cognitive Assessment (MoCa). In addition, a screening test for depression should be performed.
Laboratory testing and imaging studies:
Blood count, electrolytes, glucose, calcium, liver function tests, folate, vitamin B
12
, thyroid-stimulating hormone (TSH), and erythrocyte sedimentation rate. Consider syphilis screening if there is a risk factor or evidence of prior infection, or if patient lives in an area of high incidence. Noncontrast head computed tomography (CT) scan or magnetic resonance imaging (MRI).
ANALYSIS
Objectives
1. Develop a differential diagnosis for dementia.2. Learn how to appropriately evaluate a complaint of memory loss.3. Learn about treatment of Alzheimer dementia, the most common specific diagnosis of dementia.
Considerations
This 83-year-old woman is noted by her family to have progressive decrease in cognitive function. She is forgetful, gets lost easily, and this has been slowly but steadilyworsening. The most likely diagnosis is dementia; however, other conditions should be considered in the differential diagnosis such as medications, stroke, thyroid disorders, chronic syphilis, or other metabolic conditions. Depression can also present as dementia at times. The workup for this patient includes a careful history and physical examination, imaging of the brain, and selective laboratory tests such as TSH, vitamin B
12
level, complete blood count (CBC), and comprehensive metabolic panel. Screening for syphilis should also be considered.
APPROACH TO:
Dementia
DEFINITIONS
EXECUTIVE FUNCTIONS:
High-level cognitive abilities that control other, more basic, abilities. Executive functions include the ability to start and stop behaviors, alter behaviors to fit circumstances, and adapt behaviors to new situations.
CLINICAL APPROACH
The essential features of the diagnosis of dementia are memory loss and impairment of executive function. Dementia is a clinical diagnosis that can go unrecognized until it is inan advanced stage. Patients rarely report memory loss; the informants are usually their family members. However, relatives may fail to recognize signs and symptoms of dementia because many have a tendency to think that memory loss can be a part of normal aging. Studies of aging have shown that nonverbal creative thinking and new problem-solving strategies may decline with age, but information, skills learned with experience, and memory retention remain intact.Clinicians should assess cognitive function whenever cognitive impairment or deterioration is suspected. These concerns may be based on direct observation, patientreport, or concerns raised by family members, friends, or caretakers. Patients with dementia may have difficulty with one or more of the following: Learning and retaining new information (rely on lists, calendars) Handling complex tasks (banking, bills, payments) Reasoning (adapting to unexpected situations, unfamiliar environment) Spatial ability and orientation (getting lost driving, walking) Language (word finding, repetition, confabulation) Behavior (agitation, confusion, paranoia)The evaluation of a patient with suspected dementia should include a mental status examination. The
Folstein MMSE
is the most widely used tool in the screening for dementia. The sensitivity of the MMSE for dementia is as high as 87% and the specificity is as high as 82%. The interpretation of the score depends on the patient’s education level. It is most accurate in those with at least a high school education. Another valuable test that can be used in a busy primary care setting is the
Clock Test
. The patient is asked to draw a clock with a specific time. The patient must then accurately draw the clock face with the “big hand” and “small hand” in the correct positions. It is quick, easy to administer, and evaluates executive function in multiple cognitive domains. Other brief cognitive screening tests, such as the Short Portable Mental Status Questionnaire, modified MMSE, MoCA, and Mini-Cog (three-item recall combined with clock drawing) can be used in the primary care setting.In the evaluation of dementia, it is necessary to get information from people who know the patient well. Useful information can be obtained from informant-based functional tests, such as the functional activities questionnaire (FAQ), the instrumental activities of daily living (IADL), and caregiver burden assessments. This information can be important for physicians and families in making plans for long-term care. See Case 18 (Geriatric Health Maintenance) for more on functional assessment.
ALZHEIMER DISEASE
Alzheimer disease is the most common cause of dementia. Although a definitive diagnosis can only be made by the presence of neuritic plaques and neurofibrillary
tangles detected on autopsy, clinical diagnostic criteria have been developed (Table 32–1).
Common diagnostic criteria include the gradual onset and progression of cognitive dysfunction in more than one area of mental functioning that is not caused by another disorder
.
Table 32–1 • CRITERIA FOR PROBABLE ALZHEIMER DISEASE
Dementia confirmed by clinical and neuropsychological examinationProblems in at least two areas of mental functioningProgressive worsening of memory and mental functioningNo disturbances of consciousnessSymptoms beginning between ages 40 and 90, usually after age 65No other disorder that could cause the dementia
Data from www.ninds.nih.gov
.
The initial evaluation includes a detailed history, from both the patient and another informant (usually a spouse, child, or other close contact) and complete physical and neurologic examinations to evaluate for any focal neurologic deficit that may be suggestive of a focal neurologic lesion.
A validated test, such as the MMSE, should be used to confirm the presence of dementia
. The results of this test can also be used to follow the clinical course, as a reduction in score over time is consistent with worsening dementia. A focused evaluation to rule out other causes of dementia must be performed as well.The physical examination should focus on neurologic deficits consistent with prior strokes, signs of Parkinson disease (eg, cogwheel rigidity and/or tremors), gait abnormalities or slowing, and eye movements. Patients with Alzheimer disease generally have no motor deficits at presentation.
Depression in the elderly can present with symptoms of memory disturbance
. This is known as “pseudodementia.” As depression is common and treatable, a screening test for depression should be performed when dementia is evaluated. Similarly, hypothyroidism and vitamin B
12
deficiency are common and treatable conditions that can cause cognitive problems. TSH and vitamin B
12
levels should be performed as a routine part of the workup. Neurosyphilis could present in this fashion, but is such an uncommon diagnosis that routine screening would not be recommended. Evaluation for neurosyphilis would be warranted if there were identified high-risk factors,history of the disease, or if the patient lived in an area with a high prevalence of syphilis.Neuroimaging with either a noncontrast CT scan or an MRI of the brain is recommended to rule out other confounding diagnoses. Other testing, such as positron emission tomography (PET), genetic testing, and spinal fluid analysis are not routinely recommended. Referral to neurology is appropriate when diagnosis is uncertain.When the diagnosis of Alzheimer disease is made, a comprehensive care plan shouldbe initiated.
◦Durable Power of Attorney for Health Care