A 79-year-old man is brought to the office by his daughter. The patient has been having increasing difficulty caring for himself over the last 2 years. He is now dependent on his daughter for meal preparation, shopping, and cleaning. He will frequently go a week without bathing and often has difficulty dressing himself appropriately. The patient sometimes grows frustrated and shouts at his daughter but has never been physically violent. On direct questioning, he states that he feels fine, does not see any reason for coming to the office, and is quite suspicious of his daughter's motives. The patient has lived alone since his wife died 5 years ago. He has hypertension, osteoarthritis, and a history of remitted major depressive disorder. Medications include hydrochlorothiazide and acetaminophen as needed. Neurologic examination is nonfocal. Item 1 of 2
Which of the following is the most appropriate next step in management of this patient?

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Explanation: 11ec2b69_bfe6_1506_8f63_75ae76ebeac1_MD0005_00 This patient's presentation is concerning for dementia (ie, major neurocognitive disorder). Dementia should be suspected in patients with evidence of progressive cognitive decline that leads to functional impairment in activities of daily living. All patients with suspected dementia should undergo routine cognitive testing (eg, Montreal Cognitive Assessment) to establish an objective measure of cognitive deficit. Although <1% of dementia cases are considered reversible, workup should include routine labs-complete blood count, complete metabolic panel, TSH, and vitamin B₁₂-to rule out reversible causes. Selected cases may warrant additional labs, including folate, syphilis antibodies, vitamin D, and/or cerebrospinal fluid (CSF) studies. Most clinicians also routinely obtain an MRI of the brain as part of the workup. Thiamine deficiency and subsequent Wernicke-Korsakoff syndrome may also lead to cognitive decline; however, suspected cases are generally treated empirically as the utility of lab tests for thiamine is low. (Choice A) Genetic testing is currently not indicated for evaluation of Alzheimer disease. (Choices B and C) Patients with atypical features of dementia (eg, age <60, rapidly progressive dementia) may benefit from an electroencephalogram and/or lumbar puncture for CSF studies. (Choice D) Serum folate testing is recommended only in patients with known risk factors (eg, those taking the antifolate drug methotrexate). Educational objective: Although cases of reversible dementia are rare (ie, <1%), clinicians must rule out reversible causes prior to making a diagnosis of a specific dementia syndrome. The initial laboratory workup should include TSH, complete blood count, complete metabolic panel, and vitamin B₁₂ levels. ₁₂ References: Dementia for the primary care provider. (http://www.ncbi.nlm.nih.gov/pubmed/28797371) Rapidly progressive dementia. (http://www.ncbi.nlm.nih.gov/pubmed/27042906) The use of MRI, CT and lumbar puncture in dementia diagnostics: data from the SveDem Registry. (http://www.ncbi.nlm.nih.gov/pubmed/25358376)

A 79-Year-Old Man Is Brought to the Office by His