CASE PRESENTATION. Dr. LU, QINCHI DEPARTMENT OF NEUROLOGY REN JI HOSPITAL SHANGHAI JIAO TONG UNIVERSITY SCHOOL OF MEDICINE Tel: 58752345-3094 Email: firstname.lastname@example.org. History.
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Dr. LU, QINCHI
REN JI HOSPITAL
SHANGHAI JIAO TONG UNIVERSITY
SCHOOL OF MEDICINE
A 68-year-old woman has been noted by her daughter to have memory loss and confusion. The daughter states that her mother has been going “downhill” for the past several months. The mother has lived on her own for many years ,but recently she has begun to become unable to take care of herself.
The daughter states that her mother has become withdrawn and has lost interest in her usual activities, such as gardening and reading. Her mother’s memory is poor, and she is often fatigued. The patient states that she sleeps well at night and that her appetite is good, although she has lost 10 lb over the past 6 months. She denies bowel and urinary incontinence.
The patient’s past medical history is significant for hypertension for which she has been taking hydrochlorethiazide. The patient was last hospitalized 35 years ago when she underwent a total abdominal hysterectomy with bilateral salpingo-oophorectomy. The patient has enjoyed overall good health. She does not smoke or drink.
On examination, her blood pressure is 116/56 mmHg, her heart rate is 78 bpm, her temperature is 37.5。C, and her respiratory rate is 18 breaths per minute. She weighs 88 kg and her height is 1.62m. The patient is a well-developed white women with a flat affect. She is oriented to person, but she is not oriented to time and place.
Mini Mental Status Examination gives a score of 18 out of 30. The head and neck and cardiovascular examination are unremarkable. Abdomen is benign without hepatosplenomegaly. The extremities are without edema, cyanosis, or clubbing. The neurologic examination reveals that the cranial nerves are intact, and the motor and sensory exams are within normal limits. Cerebellum examination is unremarkable and the gait is normal.
A 68-year-old woman has memory loss, confusion, and fatigue, and is withdrawn. She had a flat affect. She is oriented to person, but she is not oriented to time and place. The remainder of the examination, including neurological examination, is normal except for a low score on the MMSE.
Assess for depression and reversible causes of dementia.
This is an elderly woman without any significant past medical history except for hypertension who was brought to your office with a history of progressive functional decline and memory loss. The first step should be to rule out depression. Depression in the elderly may have a presentation very similar to that of dementia with withdrawal, apathy, irritability, memory impairment, and confusion.
The next step should be to rule out all the possible causes of reversible or arrestable dementia, such as multi-infarct dementia, hypothyroidism, drugs, B12 deficiency, normal pressure hydrocephalus, alcoholism, HIV, and syphilis.
Laboratory tests will help you to eliminate some of these common causes of reversible dementia: complete blood count (CBC), comprehensive metabolic panel, thyroid-stimulating hormone (TSH), urinalysis, serologic test for syphilis, and a head CT (see table 49-1).
The possibility of HIV-induced dementia is not high on the differential in this case given the patient’s age, but it would certainly be a consideration in younger people. Possible infectious causes of reversible dementia include not only HIV but also neurosyphilis. Therefore, a serologic test for syphilis is indicated.
Because our patient does not have a history of chronic alcoholism, we can rule out this condition. The CBC and mean cell volume (MCV) are normal, as is the TSH, eliminating the possibilities of vitamin B12 deficiency and of hypothyroidism. The patient is only taking hydrochlorothiazide, which is not associated with the described mental status changes. A CT head scan can assess for brain lesions, multiple infarcts, and hydrocephalus.
Therefore, in this case we are left with the possibility of multi-infarct dementia and Alzheimer disease. Multi-infarct dementia develops later in life and is caused by diffuse cerebrovascular disease. Most of the patients will have a history of transient ischemic attacks and strokes, and stepwise progression of dementia which our patient does not report. In this particular case, Alzheimer dementia becomes the most likely diagnosis.
A patient who presents with memory and functional impairment should be approached from the perspective that many etiologies can be causative. A thorough description of the patient’s cognitive, adaptive, memory, and behavioral ability over time is critical. Multiple family members are often needed to construct a complete and accurate picture. The time frame (months to years versus days to weeks) is important.
A history of head trauma, neurological symptoms, a stepwise decline (multi-infarct dementia) versus a insidious gradual decline may be helpful. A record of all medications, habits, alcohol use (even remote), can potentially cause mental status changes in the elderly. A resting tremor of Parkinson disease, cold intolerance suggestive of hypothyroidism, or vitamin deficiencies may be helpful.
The other intracranial diseases that could cause a dementia-like picture include subdural hematoma and normal pressure hydrocephalus. Usually, a CAT (computed axial tomography) scan will allow you to rule out these disease processes. Also, remember, that normal pressure hydrocephalus is usually accompanied by gait disturbances and urinary incontinence which our patient does not have.
Parkinson disease is also associated with the development of dementia but patients with Parkinson disease have symptoms and physical findings that will alert you to the diagnosis. Table 49-2 lists the neurological diseases that impair cognitive ability.
The etiology of Alzheimer dementia is an unknown but Alzheimer disease has a genetic component. The risk of developing the disease for an individual in a family with Alzheimer disease increases by a factor of 3 or 4. The gene that codes for apoprotein E seems to be associated with some prediction. The pathologic changes in the brains of Alzheimer disease patients include neurofibrillary tangles with a deposition of abnormal amyloid in the brain.
Basal Forebrain and Brainstem Nuclei
The disease onset can be very insidious and the average life expectancy after diagnosis is 7-10 years. The clinical course is characterized by the progressive decline of cognitive functions (memory, orientation, attention and concentration) and the development of psychological and behavioral symptoms (wandering, aggression, anxiety, depression and psychosis) (see Table 49-3)
The goals of treatment in Alzheimer disease are to
(a) improve cognitive function
(b) reduce behavioral and psychological symptoms, and
(c) improve the quality of life.
Other issues include wakefulness, nightwalking and wandering, aggression, incontinence, and depression. A structured environment, with predictability, and judicious use of pharmacotherapy, such as selective serotonin reuptake inhibitor (SSRI) for depression or short-acting benzodiazepine for insomnia, are helpful.
The primary caregiver is a often overwhelmed and needs support. The Alzheimer Association is a national organization developed to give support to family members, and can be contacted through www.alz.org.
 C. Cholinesterase inhibitors help with the cognitive function in Alzheimer disease and may slow the progression somewhat.
 B. The stepwise decline in function is typical for multi-infarct dementia, diagnosed by viewing multiple areas of the brain infarct.
 D. The classic triad for normal pressure hydrocephalus is dementia, incontinence, and gait disturbance; one treatment is shunting the cerebrospinal fluid.
 B. Alzheimer disease typically has enlarged cerebral ventricles and brain atrophy, whereas normal pressure hydrocephalus has enlarged brain ventricles without brain atrophy.