Case Studies in Dementia Janice Knoefel MD Sandra Qaseem MD Jeremiah Kelly MD Division of Geriatrics UNM DOIM
Learning Objectives Define dementia Recognize the presentations of common types of dementia Understand why accurate diagnosis is important
Why is accurate diagnosis so important? Response to treatment Prognosis Inheritance factors Patients/ relatives want accurate diagnosis To do well in board exams!!
DSM IV - Dementia Impairment of recent memory and at least one other cognitive domain (aphasia, apraxia, agnosia, executive function). Represents a decline from previous level of function and be severe enough to interfere with daily function and independence. Occur in the absence of other psychiatric, neurologic or systemic disease Does not occur only with delirium
Clinical subtypes Alzheimer s disease 60-80% Vascular dementia 10-20% Dementia with Lewy bodies Parkinsons with Dementia Frontotemporal dementia Creutzfeld-jakob disease Reversible Dementias
Case 1 A 68 y/o man is under evaluation for memory difficulty that according to his wife began insidiously 3-4 yrs earlier Difficulty remembering recent events, appointments, conversations No longer able to manage checkbook or drive without getting lost Past medical Hx unremarkable Physical exam normal
Mental Status Exam Prominent memory loss Difficulty drawing complex figures Unable to complete clock test
Which is the most likely diagnosis? A- Alzheimer s disease B- Dementia with Lewy Bodies C- Vascular Dementia D- Frontotemporal dementia E- Creutzfeld-Jakob disease
Case -2 57 y/o man with a clerical job is brought for evaluation by his wife 3 year history of changes in memory, personality and behavior Makes loud inappropriate comments in public, recently received a poor review at work PMH- unremarkable No medications FH- mother, maternal uncle and maternal grandfather had dementia MMSE 28/30
What is the most likely diagnosis? A- mild cognitive impairment B- Alzheimer s disease C- Dementia with Lewy Bodies D- Frontotemporal dementia E- Creutzfeld-Jakob disease
Case- 3 75 y/o male presents with regular episodic confusion worse at night States that he can see people in the house, believes that his wife has been replaced by a look-a-like Some days needs help with ADL s PMH- confusion secondary to meclizine, 2 years previously Medications- none FH- no Hx dementia or neurological disease
Examination Masked facies, bradykinesia, rigidity MMSE 20/30
Which of the following is the most likely diagnosis? A- mild cognitive impairment B- Alzheimer s disease C- Frontotemporal dementia D- Dementia with Lewy bodies E- Parkinson s disease with dementia
Case- 4 66 y/o woman brought to ED for evaluation of word finding difficulty for 3 weeks, gradually worsening Began having difficulty finding her way around the offices at work 1 week ago began having difficulty finding her way around her own home and had difficulty with arithmetic calculations and vision PMH and FH unremarkable
Examination Occasional myoclonic jerks of upper extremities and facial muscles R>L MMSE 15/30 EEG shows mild diffuse slowing MRI normal
What is next test? A-Lumbar puncture B-Presenilin-1 test C-PET/ SPECT test D-Repeat EEG in 1 week E-Brain and leptomeningeal biopsy
Case-5 75 y/o man with memory loss for last 2 years Stopped driving 6 months ago because he was unable to find his way around Now has difficulty with IADL s and ADL s CVA 3 years ago affecting Right side PMH- DM and HTN, BPH MEDS: atenolol, HCTZ, glipizide FH no dementia, father died CVA
Examination BP 160/80 Mild R hemiparesis MMSE 21/30 Apraxia
What is the likely diagnosis? A- Binswanger s disease B- Alzheimer s disease C- Vascular dementia D- Parkinson s dementia
Case- 6 71 y/o lady brought to the office by her daughter with complaints of poor memory for last 6 months, she is misplacing things and losing her way around the neighborhood Weight loss of 15#, poor sleep, no interest in usual activities PMH: hypertension, atrial fibrillation, hypothyroidism MEDS: atenolol, aspirin, synthroid SH: widow for last 9 months, no alcohol/ smoking, played bridge in evenings until last 3 months FH: no dementia/ nil significant
Examination: Thin elderly female HR 72 irreg, no murmurs/gallops BP 140/80 MMSE 23/30 Geriatric depression scale 7/15
Laboratory data: TSH 5.6 CBC/ Chem 7/ LFT s nl Folate nl, B12 330ng/ml
What is the most likely effective treatment? A-Donepezil B-Memantine C-Levothyroxine increased D-Vitamin B12 supplements E-SSRI