For Student

Mr. R is a 75-year-old man who comes to see you in clinic accompanied by his wife because she
is concerned that his memory is getting worse. She states that, for the last few months, he has
been getting lost driving 20 miles from his home to his local VA hospital where he volunteers.
He has done this job twice weekly for 25 years.
past medical history chronic leg pain resulting from a war injury
ischemic bowel,
a hemicolectomy 3 years ago, and gout.
His medications are 1. Paroxetine,( antidepressant ) 20 mg daily 2. Methadone, (opioid used )20
mg 3 times a day 3. Meloxicam, 7.5 mg daily, orally 4. Acetaminophen with codeine (300/60), 2
tablets 3 times a day 5. Allopurinol 300 mg daily, orally
difficulty with recalling recent events.
Given his age, his baseline risk of dementia is at least 10%..
Further history revealed that the patient’s wife had taken over bookkeeping because a few bills
had gone unpaid during the last 3 months. The patient was given the MMSE and scored a 20 out
of 30.
He was not able to give the day of the month, could only register 2 of 3 items and recalled 0 of
3. He only got 1 of the serial 7s and could not draw pentagons. Consideration of the NINCDS-
ADRDA criteria showed him to have dementia with deficits in 2 or more areas of cognition
(orientation, visuospatial and executive functioning, attention and working memory, and
memory). At the time of the visit, it was not clear whether his cognitive functioning was
worsening and there were no disturbances in consciousness. The plan was made for initial
laboratory work to be done and for a 3-month follow-up visit. Given that he was taking multiple
psychoactive medications, his regimen was scaled back to the minimum doses necessary to
control his pain.

Tasks:

1. At this point, what is the leading hypothesis, what are the active alternatives, and is there
a must not miss diagnosis? Given this differential diagnosis, what tests should be
ordered?
Task 1 (5.0)Mr. R has had a decline in cognitive status. He is unable to do a higher-level
task that he used to do. Given that this patient is exhibiting cognitive decline, dementia—
most commonly Alzheimer disease (AD)—has to be included in the differential
diagnosis. The subacute onset of this patient’s symptoms, with loss of recall, makes AD
likely. Another common cause of dementia in older persons is vascular dementia (VaD).
It will be important to determine whether this patient has risk factors for cerebrovascular
 disease. In an older person, clinicians have to consider the normal cognitive decline that
comes with aging, but normal cognitive aging never causes functional compromise. An
alternative diagnosis is mild cognitive impairment (MCI), a syndrome of memory loss
more severe than the memory loss that occurs with normal aging. MCI, however, also
does not cause functional decline. Delirium and depression should always be considered
in an older patient with cognitive decline because they are highly treatable. A patient who
is unable to successfully live independently because of cognitive issues always has an
abnormality.

2. Have you crossed a diagnostic threshold for the leading hypothesis, AD? Have you ruled
out the active alternatives? Do other tests need to be done to exclude the alternative
diagnoses?
Task 2 (5.0)Alternative Diagnosis: Multi-infarct Dementia (Vascular Dementia, VaD). A patient
with VaD may have dementia that has an abrupt onset or is slowly worsening. The patient
usually has risk factors for vascular disease or has previously diagnosed vascular disease. The
patient often has difficulty walking or a focal neurologic exam.
Evidence-Based Diagnosis the clinical diagnosis of VaD include: 1. The development of
cognitive deficits including memory deficits 2. A resulting significant impairment in social or
occupational functioning 3. Focal neurologic signs, symptoms, or diagnostic studies indicative of
cerebrovascular disease judged to be etiologically related to the cognitive change.
DLB is typically seen in a patient with Parkinson disease who has dementia. The predominant
symptoms of the dementia are a fluctuating course and the presence of hallucinations. In patients
without a previous diagnosis of Parkinson disease, motor symptoms similar to those seen in
Parkinson disease are often present.