A 77-year-old woman is brought to the office by her son due to frequent falls and confusion. The patient began to fall without clear provocation 2 years ago. Her family didn't think anything of the falls until she began having episodes of confusion a year ago. The patient's son says, "She has good and bad days. On good days she seems almost like her old self, but on bad days she appears confused and is difficult to understand." He adds that she sometimes appears to be distracted and agitated by people or things that he cannot see. The patient's medical history includes hypertension and coronary artery disease; her mother died of a stroke and her father had several heart attacks. Temperature is 37.2 C (98.9 F), blood pressure is 140/86 mm Hg, pulse is 84/min, and respirations are 16/min. Her movements and speech are slow, she has a short-stepped gait and rigidity in her upper extremities. Montreal Cognitive Assessment is 20 on a scale of 0-30 (normal: ≥26).
Which of the following is the most likely diagnosis?

Question

A 77-year-old woman is brought to the office by her son due to frequent falls and confusion.  The patient began to fall without clear provocation 2 years ago.  Her family didn't think anything of the falls until she began having episodes of confusion a year ago.  The patient's son says, "She has good and bad days.  On good days she seems almost like her old self, but on bad days she appears confused and is difficult to understand."  He adds that she sometimes appears to be distracted and agitated by people or things that he cannot see.  The patient's medical history includes hypertension and coronary artery disease; her mother died of a stroke and her father had several heart attacks.  Temperature is 37.2 C (98.9 F), blood pressure is 140/86 mm Hg, pulse is 84/min, and respirations are 16/min.  Her movements and speech are slow, she has a short-stepped gait and rigidity in her upper extremities.  Montreal Cognitive Assessment is 20 on a scale of 0-30 (normal: ≥26). 
Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c18a_27d4_8f63_6114d3f6874e_MD0005_00 This patient's symptoms are consistent with dementia with Lewy bodies (DLB). DLB may be diagnosed in the setting of dementia (ie, progressive cognitive decline that causes functional impairment) when ≥2 of the following 4 clinical features are present: Fluctuating cognition (eg, alertness, attention) Visual hallucinations Parkinsonism Rapid eye movement sleep behavior disorder (ie, loss of normal rapid eye movement sleep atonia). DLB typically presents around age 75 and is 4 times more common in men. DLB is the second leading cause of dementia behind Alzheimer disease and may account for up to a third of cases of dementia. The survival time after initial diagnosis of DLB is approximately 8 years. (Choice A) Parkinsonism and visual hallucinations are not consistent with Alzheimer disease. Early, prominent, and relatively isolated amnestic symptoms are characteristic of the disease. (Choice C) Although some variants of frontotemporal dementia may involve motor syndromes, frontotemporal dementia typically presents with early personality changes (eg, disinhibition) that initially predominate over cognitive dysfunction. (Choice D) The classic triad of normal-pressure hydrocephalus (NPH) consists of cognitive impairment, urinary incontinence, and abnormal gait. Gait dysfunction in patients with NPH (eg, magnetic gait) can appear similar to a parkinsonian gait (shuffling); however, rigidity and bradykinesia are not present in NPH. (Choice E) Vascular dementia typically presents with early executive dysfunction, focal neurological findings, and evidence of cerebrovascular disease on imaging of the head. It would not explain this patient's fluctuating symptoms, parkinsonism, and visual hallucinations. Educational objective: Dementia with Lewy bodies presents with dementia and ≥2 of the following: Fluctuating cognition (eg, alertness, attention), visual hallucinations, parkinsonism, and/or rapid eye movement sleep behavior disorder (ie, loss of normal rapid eye movement sleep atonia). References: Diagnosis and management of dementia with Lewy bodies: fourth consensus report of the DLB Consortium. (http://www.ncbi.nlm.nih.gov/pubmed/28592453) Cholinesterase inhibitors for dementia with Lewy bodies, Parkinson's disease dementia and cognitive impairment in Parkinson's disease. (http://www.ncbi.nlm.nih.gov/pubmed/22419314)

A 77-Year-Old Woman Is Brought to the Office by Her