An 81-year-old woman is brought to the office for assessment of behavioral changes over the past 10 months. The patient moved to a nursing home a year ago, and initially enjoyed playing simple card games there with other residents. Now she either seems uninterested in playing or quickly becomes upset during games, repeating, "I can't, I can't, I can't." She also becomes easily irritable and pushes staff away when they try to help her dress or comb her hair. The patient has had increasing difficulty recalling recent events and has started accusing staff of stealing her jewelry. Sleep and appetite are unchanged. The patient has a history of hypertension and noninsulin-dependent diabetes mellitus, as well as postpartum depression in her 20s. Temperature is 37 C (98.6 F), blood pressure is 140/90 mm Hg, and pulse is 86/min. Physical examination is unremarkable. She is oriented to person and place but not to time or day. Short-term recall is very poor. Her mood is "OK." Laboratory results, including electrolytes, complete blood count, thyroid function tests, and vitamin B₁₂, are normal. Rapid plasma reagin is negative; fluorescent treponemal antibody absorption test is nonreactive. MRI of the brain reveals mild generalized cortical atrophy and slightly reduced hippocampal volume. Which of the following is the most appropriate statement regarding this patient's prognosis?

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Explanation: 11ec2b69_bfe5_78c5_8f63_514c80149a33_MD0005_00 This patient has gradually progressive symptoms (eg, poor memory, apraxia, language difficulties, executive dysfunction) that suggest a diagnosis of Alzheimer disease (AD). Onset occurs at age >60 and initially affects memory and language predominantly. Later in the course of the illness, behavioral symptoms become more prominent. Patients typically become more easily irritable, especially when frustrated or overwhelmed. Paranoid delusions are common and usually due to misattribution. Cholinesterase inhibitors can sometimes slow the progression of AD, but there is no cure. The disease is progressive and the patient may eventually die from complications of an infection, dehydration, or malnutrition. The differential diagnosis for AD includes other dementing illnesses and cognitive changes due to delirium or psychiatric illness (eg, depression). This patient's lack of other depressive symptoms (eg, sleep and appetite are unchanged, mood is not depressed), stable medical condition, and progressive decline over 10 months make AD more likely. dementing illnesses (Choice A) This patient's agitated behavior and delusions of items being stolen are common in moderate to severe dementia (often due to patients forgetting where an item was placed). Behavioral symptoms in AD are ideally managed with nonpharmacological interventions, with antipsychotics reserved for situations in which agitated behaviors pose a risk to self or others. (Choice C) In the absence of syndromal depression, antidepressants are unlikely to improve this patient's condition. When cognitive impairments are due to depression, antidepressants can help to reverse these deficits. (Choice D) Stepwise decline occurs with vascular dementia, which is characterized by stepwise cognitive decline as well as focal neurological symptoms. Brain imaging may reveal multiple small cortical and subcortical infarcts. The patient has hypertension and diabetes as risk factors but no findings consistent with vascular dementia. (Choice E) Delirium is always secondary to an underlying medical process or drug effect; the patient's mental status improves once it resolves. Delirium can also manifest with delusions, memory impairment, or agitation. The hallmark of delirium is acute onset of altered level of consciousness with difficulty in sustaining attention, which is not present in this patient. Educational objective: Alzheimer disease is a progressive illness characterized by memory loss and functional decline across several cognitive domains. Medications may slow progression, but there is no cure. References: Neurocognitive disorders in DSM-5: pervasive changes in the diagnostics of dementia. (http://www.ncbi.nlm.nih.gov/pubmed/24744097) Differential diagnosis of dementia. (http://www.ncbi.nlm.nih.gov/pubmed/19351220)

An 81-Year-Old Woman Is Brought to the Office for Assessment