A 63-year-old woman is brought to the office due to a change in behavior over the past year. The patient was a highly successful CEO of a large company but had to step down 3 months ago due to poor performance. She once excelled in organization and strategic planning, but 9 months ago, she began to have significant difficulty planning important meetings. Now the patient is unable to shop and cook for herself. She has had recent bouts of sadness and urinary frequency. Medical history is significant for hypertension and type 2 diabetes mellitus. Temperature is 37.1 C (98.8 F), blood pressure is 132/79 mm Hg, pulse is 76/min, and respirations are 14/min. The patient scores 23/30 (normal: ≥26) on the Montreal Cognitive Assessment. Gait is slow and unsteady. Extraocular movements are intact. Reflexes are 3+ in the left upper extremity and 2+ on the right. Which of the following is the most likely diagnosis in this patient?

Question

A 63-year-old woman is brought to the office due to a change in behavior over the past year.  The patient was a highly successful CEO of a large company but had to step down 3 months ago due to poor performance.  She once excelled in organization and strategic planning, but 9 months ago, she began to have significant difficulty planning important meetings.  Now the patient is unable to shop and cook for herself.  She has had recent bouts of sadness and urinary frequency.  Medical history is significant for hypertension and type 2 diabetes mellitus.  Temperature is 37.1 C (98.8 F), blood pressure is 132/79 mm Hg, pulse is 76/min, and respirations are 14/min.  The patient scores 23/30 (normal: ≥26) on the Montreal Cognitive Assessment.  Gait is slow and unsteady.  Extraocular movements are intact.  Reflexes are 3+ in the left upper extremity and 2+ on the right.  Which of the following is the most likely diagnosis in this patient?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d5d6_21d2_bc81_7f128e0d3ab7_MD0003_00 Dementia, also known as major neurocognitive disorder, is characterized by progressive cognitive impairment that interferes with activities of daily living (eg, shopping, cooking). This patient's dementia with executive dysfunction (eg, difficulty planning meetings) and neurologic findings (eg, asymmetric reflexes, urinary frequency, gait abnormalities) is most consistent with the subtype known as vascular dementia (VaD). Patients with VaD may also experience depressive symptoms, as seen in this patient. VaD is caused by ischemia or overt infarction in the large or small arterial distributions in the brain, and all patients with suspected VaD should undergo neuroimaging to evaluate for cerebrovascular disease. VaD may be accompanied by cortical or subcortical neurologic signs/symptoms, depending on the arterial network affected. Large artery infarction (often causing an overt stroke) produces a cortical-type VaD, in which accompanying neurologic signs/symptoms reflect the specific cortical region involved (eg, middle cerebral artery infarction causing contralateral weakness and sensory impairment) and typically follow the classic stepwise worsening course. Infarcts and ischemia in small arterial distributions, as seen in this patient, lead to a subcortical-type VaD, which is characterized by focal motor deficits (eg, reflex asymmetry), abnormal gait, urinary symptoms, and psychiatric symptoms (eg, depressive syndromes). Subcortical VaD frequently has a more gradual declining course. (Choice A) Alzheimer disease, the most common subtype of dementia, presents with prominent memory impairment. Urinary symptoms and abnormal reflexes would be unusual and more likely to occur at late stages. (Choices B and D) Dementia with Lewy bodies is characterized by dementia accompanied by at least 2 of the following signs/symptoms: parkinsonism, visual hallucinations, fluctuating cognitive status, and REM sleep behavior disorder. It is distinguished from Parkinson disease dementia primarily by timeline: In Parkinson disease dementia, parkinsonism predates dementia symptoms by ≥1 year. (Choice C) Frontotemporal dementia is characterized by early personality change (eg, disinhibition) and hyperorality. It is not associated with focal neurologic deficits (eg, asymmetric reflexes). Educational objective: Vascular dementia (VaD) is caused by large or small artery ischemia or infarction and presents with executive dysfunction and focal neurologic findings. Patients with suspected VaD should undergo neuroimaging to evaluate for cerebrovascular disease. References: Vascular dementia. (http://www.ncbi.nlm.nih.gov/pubmed/26595643)

A 63-Year-Old Woman Is Brought to the Office Due to a Change