A 76-year-old woman comes to the office for a routine checkup. Her medical history is significant for hypertension, type 2 diabetes mellitus, and hypothyroidism that are treated with oral agents. The patient had a stroke a year ago and has mild residual weakness in the right arm. Otherwise, she has no physical symptoms but is concerned about becoming more forgetful, especially because her mother died of Alzheimer disease. She says, "Sometimes I can't remember people's names, and occasionally during conversations, I can't seem to find the right word." The patient is widowed and lives alone. She drives herself to the grocery store weekly and manages her own finances. She describes her mood as "just okay," misses her husband, and regrets that she lives far from her children and grandchildren. The patient plays cards with her close friends regularly and is looking forward to a trip to visit her family. Her appetite is good, but she falls asleep earlier in the evening than before, awakening earlier in the morning and having less energy during the day. Blood pressure is 135/76 mm Hg and pulse is 65/min. Finger-stick glucose is 94 mg/dL and TSH is 2.4 µU/mL. She scores 26/30 on the Montreal Cognitive Assessment. Which of the following is the most likely diagnosis in this patient?

Question

A 76-year-old woman comes to the office for a routine checkup.  Her medical history is significant for hypertension, type 2 diabetes mellitus, and hypothyroidism that are treated with oral agents.  The patient had a stroke a year ago and has mild residual weakness in the right arm.  Otherwise, she has no physical symptoms but is concerned about becoming more forgetful, especially because her mother died of Alzheimer disease.  She says, "Sometimes I can't remember people's names, and occasionally during conversations, I can't seem to find the right word."  The patient is widowed and lives alone.  She drives herself to the grocery store weekly and manages her own finances.  She describes her mood as "just okay," misses her husband, and regrets that she lives far from her children and grandchildren.  The patient plays cards with her close friends regularly and is looking forward to a trip to visit her family.  Her appetite is good, but she falls asleep earlier in the evening than before, awakening earlier in the morning and having less energy during the day.  Blood pressure is 135/76 mm Hg and pulse is 65/min.  Finger-stick glucose is 94 mg/dL and TSH is 2.4 µU/mL.  She scores 26/30 on the Montreal Cognitive Assessment.  Which of the following is the most likely diagnosis in this patient?

Quizplus · Accepted Answer

11ec25c8_d750_185e_bc81_cf2339d15476_MD0003_00 As patients age, they tend to have a lower energy level and slower processing speed that affects memory and executive functioning (eg, planning, working memory, mental flexibility) to a small degree. This patient-with well-controlled diabetes, hypertension, and hypothyroidism and no new focal neurologic deficits (baseline right arm weakness is due to prior stroke)-likely has normal age-related changes. Such changes do not impact activities of daily living (ADLs) (eg, self-care, finances, medication management) and are associated with normal scores on objective measures of cognition (eg, Montreal Cognitive Assessment [MoCA] score ≥26/30). Patients can have occasional word-finding difficulty (expressive aphasia) or mild memory loss but are able to provide details about incidents of forgetfulness. Changes in sleep pattern, including lighter sleep and phase advance (ie, falling asleep earlier in the evening and awakening earlier), are also common. By contrast, with mild cognitive impairment (MCI), there is a objective evidence of impairment (eg, MoCA score <26/30) and modest but notable decline in cognitive function (eg, complex attention, executive function, learning and memory, language). Although independence is generally preserved, ADLs take greater effort, time, and/or compensatory strategies. This patient does not demonstrate impairment in ADLs, does not need to compensate to function, and shows no objective evidence of impairment on neuropsychological screening (Choice D). (Choices A and F) Dementia (also known as major neurocognitive disorder) may be differentiated from MCI by the severity of cognitive dysfunction as well as by the functional impairment of ADLs. Alzheimer disease presents with insidious onset and gradual progression of memory impairment (particularly memory for recent events or of specific events at specific times). Vascular dementia manifests with prominent executive dysfunction and mild memory impairment, focal neurologic findings, and signs of cerebrovascular disease on brain imaging. (Choice B) Depression is a common cause of reversible cognitive impairment in the elderly and is sometimes referred to as pseudodementia. This patient's lack of core depression symptoms (dysphoria or anhedonia) makes pseudodementia an unlikely explanation for her symptoms. (Choice C) Overt hypothyroidism (ie, elevated TSH with low free T4) may be associated with a reversible hypothyroid-induced cognitive impairment characterized by deficits in short-term memory and concentration. This patient has no evidence of hypothyroidism on laboratory testing. Educational objective: Normal age-related cognitive changes include occasional forgetfulness, word-finding difficulty, and sleep pattern changes that do not impact activities of daily living. References: Normal cognitive aging. (http://www.ncbi.nlm.nih.gov/pubmed/24094294) What is normal in normal aging? Effects of aging, amyloid and Alzheimer's disease on the cerebral cortex and the hippocampus. (http://www.ncbi.nlm.nih.gov/pubmed/24548606)

A 76-Year-Old Woman Comes to the Office for a Routine