A 74-year-old man is brought to the physician by his son for forgetfulness. Over the last 2 years, the patient has missed several important appointments, often forgets to take his medication, and has limited his social interaction. Two months ago, he got lost in the neighborhood he has lived in for the last 20 years. The patient says he is "fine and in good spirits." He is a retired mathematics professor.
Neurologic examination, including gait assessment, is unremarkable. His mini-mental state examination score is 26/30.
Which of the following is the most likely diagnosis?

Question

A 74-year-old man is brought to the physician by his son for forgetfulness.  Over the last 2 years, the patient has missed several important appointments, often forgets to take his medication, and has limited his social interaction.  Two months ago, he got lost in the neighborhood he has lived in for the last 20 years.  The patient says he is "fine and in good spirits."  He is a retired mathematics professor.
Neurologic examination, including gait assessment, is unremarkable.  His mini-mental state examination score is 26/30.
Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

This highly educated patient likely has Alzheimer dementia despite his normal mini-mental state examination (MMSE) score as he has symptoms of cognitive dysfunction (eg, memory loss, visuospatial impairment) that are affecting his daily activities (eg, managing medications). An MMSE score <24 is 87% sensitive and 82% specific for dementia; however, individuals with very mild dementia or those who are highly educated with dementia can have normal scores. One study showed that in individuals without cognitive dysfunction, the median MMSE score is 29 with >9 years of education and 26 with 5-8 years of education. Some experts suggest the cutoff for dementia be increased to a score of 27 in older individuals with a college education. (Choice B) This patient's lack of fluctuating cognition, Parkinson symptoms, and visual hallucinations makes dementia with Lewy bodies less likely. (Choice C) Patients with late-life depression can have a normal MMSE score, but they usually have somatic symptoms and changes in mood, which are not evident in this patient. (Choices D and E) By definition, normal aging and mild cognitive impairment should not significantly impair daily activities. Educational objective: Individuals with very mild dementia or those who are highly educated with dementia can have normal mini-mental state examination scores. __________ References: Detecting dementia with the mini-mental state examination in highly educated individuals. (http://www.ncbi.nlm.nih.gov/pubmed/18625866) The initial recognition and diagnosis of dementia. (http://www.ncbi.nlm.nih.gov/pubmed/9617846)

A 74-Year-Old Man Is Brought to the Physician by His