A 74-year-old woman comes to the office accompanied by her husband for a routine checkup. The patient has a history of hypertension and hypercholesterolemia. She has no other medical problems or physical limitations. At today's visit, her blood pressure is elevated and her husband says that she often forgets to take her blood pressure pills. The patient says, "It's hard to remember to take them every day." Her husband believes that her speech has changed as she occasionally struggles to find appropriate words and sometimes cannot recall people's names. Two days ago, she drove to a nearby grocery store and was unable to find her way back. She naps during the day, has difficulty falling asleep at night, and always wakes up early in the morning. Her appetite is good. Physical examination is within normal limits. On mental status examination, the patient is calm and cooperative. She says her mood is good and scores 25/30 on the Mini-Mental State Examination. Which of the following is the most specific indicator of dementia (major neurocognitive disorder) as opposed to normal aging in this patient?

Question

A 74-year-old woman comes to the office accompanied by her husband for a routine checkup.  The patient has a history of hypertension and hypercholesterolemia.  She has no other medical problems or physical limitations.  At today's visit, her blood pressure is elevated and her husband says that she often forgets to take her blood pressure pills.  The patient says, "It's hard to remember to take them every day."  Her husband believes that her speech has changed as she occasionally struggles to find appropriate words and sometimes cannot recall people's names.  Two days ago, she drove to a nearby grocery store and was unable to find her way back.  She naps during the day, has difficulty falling asleep at night, and always wakes up early in the morning.  Her appetite is good.  Physical examination is within normal limits.  On mental status examination, the patient is calm and cooperative.  She says her mood is good and scores 25/30 on the Mini-Mental State Examination.  Which of the following is the most specific indicator of dementia (major neurocognitive disorder) as opposed to normal aging in this patient?

Quizplus · Accepted Answer

11ec25c8_d790_54f0_bc81_d34b329333ef_MD0003_00 This elderly patient has forgetfulness, word-finding aphasia, impairment of daily functioning, and insomnia. Of these symptoms, the most specific for dementia (major neurocognitive disorder) is her impaired functioning in daily activities as demonstrated by getting lost in familiar surroundings. Other areas of impaired functioning in dementia can include difficulties with dressing, maintaining personal hygiene, food acquisition and intake, self-administration of medications, social interactions, and operating common appliances. (Choices A, E, and F) Normal age-related cognitive decline involves nonprogressive, mild memory impairment and decreased rate of information processing that does not result in interference with daily function. Sometimes forgetting to take medication without reminders, occasional word-finding aphasia, and sleep disturbance can also occur with normal aging and are therefore less specific for dementia. In contrast, patients with age-related memory loss will not get lost in familiar settings. (Choice C) The Mini-Mental State Examination is a widely used screening test for delirium or dementia. However, scores <23 are usually considered suggestive of these conditions, and higher cutoff scores are associated with lower specificity. The test is also much less sensitive for mild dementia as performance can be influenced by educational level and age (eg, this patient's score of 25 could be normal or significant depending on her education level). < (Choice D) Patients with dementia are more commonly unaware of their deficits and do not complain of memory loss. Informant-reported memory loss is a better predictor of dementia. Educational objective: Cognitive deficits that interfere with independence in everyday activities are a key feature that distinguishes dementia (major neurocognitive disorder) from normal age-related changes. Patients with dementia have functional impairments that necessitate assistance. References: Normal cognitive aging. (http://www.ncbi.nlm.nih.gov/pubmed/24094294) A practical approach to dementia in the outpatient primary care setting. (http://www.ncbi.nlm.nih.gov/pubmed/25979581)

A 74-Year-Old Woman Comes to the Office Accompanied by Her