| FORGETFULNESS
Doorway information about patient
The patient is a 70-year-old woman who comes to the clinic due to episodes of forgetfulness.
Vital signs . Temperature : 36.1¡¦C(97.0F) . Blood pressure : 150/85 mmHg . pulse: 76/min . Respiratory rate: 16/min
Approach to the patient
Cognitive impairment in elderly patients
Normal aging . Slight decrease in fluid intelligence (ability to process new information quickly) . - Normal functioning- in all activities of daily living.
Mild neurocognitive disorder (mild cognitive impairment) . Mild declined >= 1 cognitive domains . Normal functioning in all activities of daily living with compensation
Major neurocognitive disorder (dementia) . Significant decline in >=1 cognitive domains . -irreversible- global cognitive impairment . Marked functional impairment . Chronic & progressive , months to years
Major depression . -Reversible- mild -moderate cognitive impairment . Features -depression-(mood , interest, energy) . Episodic , weeks to months
The first in evaluation of possible -dementia- is to assess the - acute and severity- of the impairment . Severity should be rate with objective tests (eg , Mini -Mental State Examination) and a subjective discussion of how the problem affects the patient¡¦s activities of daily living. Second , determine whether the symptom s involve only learning and memory , or additional -neurocognitive domains- (eg, complex attention , perceptual-motor-function, language , executive function, social cognition) , Finally , use the physical examination and diagnostic testing to identify and -underlying medical conditions -or reversible causes of impairment.
Different diagnosis
Alzheimer disease . -Early , insidious short -term memory loss- . Language deficits& spatial disorientation . Later personality changes
Vascular dementia . -Stepwise- decline . Early executive dysfunction . -Cerebra infarction- &/or deep white matter changes on neuroimaging
Frontaltemporal dementia . -Early personality changes- . Apathy , disinhibition & compulsive behavior . -Frontotemporal atrophy- on neuroimaging
Normal pressure hydrocephalus . -Ataxia -early in disease . Urine -incontinence- . -Dilated ventricles- ion neuroimaging
Prion disease . Behavior changes . -Rapid progression- . -Myoclonus- &/or seizure
The primary types of -dementia- are listed in the table . Alzheimer dieseae is most common . Other -neuropsychiatric disorders- amy manifest as memory impairment (eg, major depression, multiple sclerosis) . -Metabolic disorders- (eg, hypothyroidism, vitamin B12 deficiency0 should be considered and screened for initial testing. Finally , -medications -(ego tricyclic antidepressants, benzodiazepines) and -alcohol abuse- are major causes of cognitive dysfunction.
HISTORY AND PHYSICAL EXAMINATION
\Be sure to pay attention to the time when interviewing a patient with memory loss, as the clinical examination may be lengthy.
History
History of present illness . Please tele about your memory problems. . How long has this been going on ? Is it getting worse? . Do you have any problems sleeping? . Do you have nay trouble preparing meals for yourself? Doing your shopping & housekeeping ? bathing /personal hygiene? Managing your finances? Driving? . Have you felt sad or lonely? . Do you have dizzy spell or falls? . Do you feel cold when everyone else feels comfortable? . Have you noticed any weight loss? . What do you think may be causing you problem, or what are you concerned for?
Past medical history . Have you had a similar problem before? . Have you been diagnosed with any otters medical conditions (eg, diabetes, thyroid conditions)?
Medications/ allergies . Do you take any medications (prescriptions, over-the-counter)? . How long have you been on these medications?
Social history . Who do you live with / Do you have someone to take care of you in an emergency? . What kind of work do(did) you do? . Do you smoke? . Do you drink alcohol? How much &how often? . Have you used recreational drugs?
Physical examination
General
. Attention & alertness . Grooming & hygiene . Nutrition & hydration
Neck . Examine thyroid
Cardiac . Auscultate the heart . Auscultate carotid ofr bruits
Neurologic
. Cranial nerve examination . ¡§Get up and go ¡§ test /gait . Power & reflexes . Cerebellar signs . Lower extremity sensory (position &vibration)
- Mini-Mental state Exam - . What is the year ? Season ? month ? Date? Day ? (1 point each) . What country are we in ? State ? City ? Facility ? Floor (1 point each) . Name 3 common objects & ask patient to repeat (eg , bird , car , banana)(1 point each) . Count backward form 100 by 7¡¦s (alternate : spell ¡§world¡¨ backward)(1 point each, up to 5) . Name the 3 objects mentioned above (1 point each) . Point to 2 object in the room (eg, clock , pen ) & ask patient to identify them (1 point each) . Repeat the following : ¡§ No if ¡¦s and ,or but¡¦s¡¨(1 point) . 3-stage command : ¡§ take this paper in your right hand , food it in half & place it on the floor¡¨ (1 point each) . Write a command (¡§ close your eye¡¨) & ask patient to read & obey it(1 point) . Ask the patient to write a sentence(1 point) . Draw 2 interesting pentagons & ask patient to copy it(1 point) a score of <24/30 possible dementia
Psychiatric
. Mood /affect . Psychomotor activity . Speech/ language
Closing the encounter Elderly patient have often seen how dementia has affect their friends or family members , and may be concerned about losing cognitive function and becoming a burden on their family. In light of this , physicians should be honest about whatever cognitive deficits they observe , but should also explain that there may be other possible explanations for the patient¡¦s symptoms.
Explain that you will be looking for treatable disorders (eg, hypothyroidism) that can masquerade as dementia , and that even if the patient has dementia there may be treatment available to improve the symptoms or slow the progression of the disease . Also discuss what family support and community resources are available to the patient.
Diagnostic testing
Most patients with memory impairment should have a -TSH- and -vitamin B 12- assay, Additional tests are based on the patient¡¦s clinical features . Possible test include:
. Electrolytes and glucose . Blood urea nitrogen and creatinine . Liver function panel . Complete blood count . Urinalysis . Urine toxicology (drug ) screen
In addition , the status of chronic disease should be assessed (eg, hemoglobin A1c for diabetes ) , and therapeutic drug levels (eg, digoxin) should be checked . -Neuroimaging-(eg, CT scan, MRI) is ordered in mist cases but is not mandatory . lumber puncture and more obscure tests (eg,heavy metal screen) are not typically done in the initial workup.
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