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Message ¬d¬Ý¡@·j´M¡@³q°T¿ý¡@½Æ»s¡@¤Þ¥Î¡@¦^ÂФ峹¦^ÂС@[²Ä 20 ¼Ó]
 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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