A 78-year-old man is brought to the office by his daughter, who states that he has become forgetful. Over the past year, his responses have become slow, and he has had increasing difficulties in caring for himself. He was recently seen by another physician, who suspected a "certain type of anemia." He has no urinary or respiratory problems. The patient was previously diagnosed with hypertension and coronary artery disease. He takes lisinopril, metoprolol, and aspirin. He lives with his daughter and son-in-law. He does not use tobacco, alcohol, or illicit drugs. Examination shows an elderly man who is disoriented to time and place and communicates poorly. He speaks softly and slowly and seems to think too much about his answers. The mini-mental state examination (MMSE) score is 22 points (normal 24). The patient's gait is slow and cautious, as if he were expecting to fall. Laboratory test results are as follows: Which of the following is the most appropriate next step in the management of this patient?

Question

A 78-year-old man is brought to the office by his daughter, who states that he has become forgetful.  Over the past year, his responses have become slow, and he has had increasing difficulties in caring for himself.  He was recently seen by another physician, who suspected a "certain type of anemia."  He has no urinary or respiratory problems.  The patient was previously diagnosed with hypertension and coronary artery disease.  He takes lisinopril, metoprolol, and aspirin.  He lives with his daughter and son-in-law.  He does not use tobacco, alcohol, or illicit drugs.  Examination shows an elderly man who is disoriented to time and place and communicates poorly.  He speaks softly and slowly and seems to think too much about his answers.  The mini-mental state examination (MMSE) score is 22 points (normal >24).  The patient's gait is slow and cautious, as if he were expecting to fall.  Laboratory test results are as follows:  Which of the following is the most appropriate next step in the management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_bff7_5328_8f63_a1982f62fd38_MD0005_00 This patient has disordered gait, impaired language, chronic cognitive decline, and abnormal findings on mental status examination; these are typical features of dementia. Even though most cases of dementia are due to Alzheimer's disease, approximately 20% of patients have a potentially reversible cause. For this reason, the American Academy of Neurology (AAN) currently recommends screening for hypothyroidism, vitamin B₁₂ deficiency, and depression as part of the initial evaluation of all patients with suspected dementia. Additional testing may be indicated for individual patients depending on history or examination findings (eg, hepatic function tests in patients with signs of ascites on examination). In this case, hyponatremia, macrocytosis, bradypsychia (slowed thought process), and slowed speech suggest underlying hypothyroidism, which should be ruled out by assessing serum TSH. ₁₂ (Choices A and B) The AAN also recommends cerebral imaging with MRI or head CT for the evaluation of dementia. Imaging may identify signs of chronic vascular disease, subdural hematoma, or normal pressure hydrocephalus (NPH). Patients with NPH may have a shuffling broad-based gait but a "cautious gait" is nonspecific and can be seen in normal elderly patients. Correcting the underlying hypothyroidism may obviate the need for imaging in this case. (Choice C) Screening for syphilis in a patient with dementia is not routinely recommended, though it may be considered if the patient has specific risk factors or evidence of a prior syphilitic infection. (Choice E) Depression is probably the most common cause of reversible dementia; however, it does not explain the hyponatremia or macrocytosis seen in this patient. If depression is suspected, a brief depression screen (eg, Geriatric Depression Scale) would be indicated prior to psychiatry referral. Educational objective: Approximately 20% of cases of dementia are due to potentially reversible conditions. In particular, hypothyroidism, vitamin B₁₂ deficiency, and depression should be ruled out in the initial evaluation of dementia. Hypothyroidism in elderly patients may present with impaired cognition and is often associated with hyponatremia and macrocytosis. ₁₂ References: Cognitive and neuropsychiatric aspects of subclinical hypothyroidism: significance in the elderly (http://www.ncbi.nlm.nih.gov/pubmed/13678560)

A 78-Year-Old Man Is Brought to the Office by His