An 80-year-old retired engineer is brought to the office by his son due to behavioral changes. The patient believes that his son is after his money and is trying to kick him out of the house to get all of his property. His son reports the patient has been more forgetful over the last few years. Medical history is nonsignificant. Vital signs are within normal limits. On physical examination, the patient is oriented to person and place only and is unable to cooperate with much of the cognitive examination. He has very poor short-term recall. He is unable to name the current American president and states, "I don't care to follow politics anymore." The remainder of the neurologic examination is unremarkable. Which of the following is the most likely diagnosis?

Question

An 80-year-old retired engineer is brought to the office by his son due to behavioral changes.  The patient believes that his son is after his money and is trying to kick him out of the house to get all of his property.  His son reports the patient has been more forgetful over the last few years.  Medical history is nonsignificant.  Vital signs are within normal limits.  On physical examination, the patient is oriented to person and place only and is unable to cooperate with much of the cognitive examination.  He has very poor short-term recall.  He is unable to name the current American president and states, "I don't care to follow politics anymore."  The remainder of the neurologic examination is unremarkable.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec25c8_d756_8106_bc81_699a4132b558_MD0003_00 The insidious onset of memory impairment followed by the development of paranoid ideation in a previously high functioning patient is characteristic of Alzheimer disease (AD). AD, the most common cause of dementia, typically begins with memory loss for recent events (eg, poor short-term memory, naming current president), executive dysfunction, and impaired visuospatial skills, followed by language difficulties, apraxia, and behavioral changes (eg, apathy, disinhibition, suspiciousness). Psychotic features (delusions, hallucinations) may develop in the middle and late course of the disease. Delusions with paranoid themes are common and can be particularly distressing to both patients and caregivers. Common disorders in the differential diagnosis of AD include vascular dementia, pseudodementia (cognitive changes due to depression), and other neurodegenerative dementias (eg, dementia with Lewy bodies, frontotemporal dementia). Although the diagnosis of AD is largely clinical, neuropsychological testing, brain imaging, and laboratory testing are typically ordered to rule out reversible causes of dementia. (Choice B) Dementia with Lewy Bodies is characterized by fluctuating cognitive impairment, dysautonomia, parkinsonism, and early development of visual hallucinations. This patient's early, prominent memory loss and unremarkable neurologic examination are more consistent with AD. (Choice C) Frontotemporal dementia is characterized by early personality changes (eg, euphoria, disinhibition, apathy), compulsive behaviors (eg, peculiar eating habits), hyperorality, and frontotemporal atrophy demonstrated on brain imaging. Behavioral changes often precede memory impairments (in contrast to AD). (Choice D) Pseudodementia (also referred to as dementia syndrome of depression) is seen in older depressed patients who present with cognitive deficits similar to neurodegenerative dementias. It is less likely in this patient who has no history of depression or prominent mood symptoms. (Choice E) Vascular dementia is associated with stroke or small-vessel cerebrovascular disease. The dementia is typically characterized by stepwise cognitive impairments associated with focal neurologic deficits. It is less likely in this patient with no significant cardiovascular risk factors and a normal examination. Educational objective: Alzheimer disease, the most common cause of dementia, is characterized by insidious memory loss followed by behavioral changes. Psychotic symptoms (delusions, hallucinations) may develop later in the course of the disease. References: The Alzheimer's disease clinical spectrum: diagnosis and management. (http://www.ncbi.nlm.nih.gov/pubmed/30704681)

An 80-Year-Old Retired Engineer Is Brought to the Office by His