| | 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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2018/05/24 09:57pm 
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