Dementia - A Typical Case

81 yo CF, a widow for several years, lives alone in her house. She has no children or any other family, and does the shopping and cooking by herself. She is very friendly and sometimes ask her neighbor for help with the shopping.

She was stopped by the police for driving disoriented and confused, not knowing where she was going. She is hospitalized for further work-up.

What do you think is going on?
Remember the mnemonic DDD:
Delirium? But why? What is the cause?
Dementia?
Depression?
Subdural hemorrhage?

PMH: HTN, hyperlipidemia, ITP (last platelet count was 59), DJD

Medications: Danazol (for ITP), Lipitor, Lisinopril, Protonix, Tylenol prn

SH: Lives alone, no living relatives

What would you do?
First, you need to do a MMSE - it is 20/30 (she had a high school diploma; remember that the normal MMSE score varies with the level of education).
She is a very friendly lady but extremely forgetful. She is oriented just to herself, not to place or time.

Physical exam is unremarkable.

What tests would you order?
Next, you need to rule out any reversible cause:
-Infection - UTI, pneumonia
-Delirium
-Depression
-Hypothyroidism
-B12 deficiency
-Syphilis

The tests are:
CBCD, CMP, UA, TSH, B12, B9, RPR
Head CT or MRI

If you need to remember just 4, go for: TSH, B12, RPR and CT of the head.

What happened?
Patient was started on Aricept 5 mg po qd.
Her neighbor was appointed as a guardian and she was admitted to an assisted living facility.

Final diagnosis: Alzheimer's dementia

What did we learn from this case?
Dementia is common in the elderly. If we are lucky enough to live long enough, probably all of us will develop some degree of cognitive impairment.

If the patient does not have a family, a guardian should be appointed (through the court) to make health care decisions on behalf of the patient.

MMSE showing the progressive decline of a patient with Alzheimer's dementia over 5 years.


MMSE of a demented patient over 5 years

More Info
Dementia prevalence doubles every 5 years after age 60. It is rare below 65 (1%) but affects around 50% of those older than 85. Seventy percent of the elderly NH residents are demented.

There are 2 major causes of dementia in the elderly: Alzheimer's disease and vascular dementia.

Sixty percent of dementia is due to Alzheimer's disease, 15 percent is due to vascular disease and many of the remaining cases involve both Alzheimer's and vascular dementia in the same patient ("mixed dementia").

Diagnostic criteria for delirium
/\MS not explained by dementia.
/\MS developed over a short period of time (hours to days) and fluctuates
/\MS could be explained by a drug, acute illness or metabolic disturbance

Diagnostic criteria for dementia
Memory loss, impairment of language, praxis, recognition or abstract thinking
Chronic and progressive
Delirium ruled out

Diagnostic criteria for Alzheimer's disease
Dementia is present, verified by MMSE
Screening blood tests (CBC, BUN, Ca++, LFT, TSH, B12, B9, RPR) do not show any untreated cause
Head CT or MRI are normal or show atrophy

Diagnostic criteria for vascular dementia
Dementia is present, verified by MMSE
Focal neurologic signs on exam
Abrupt onset with stepwise progress or stroke-related
Head CT or MRI show multiple strokes

References:
Advances in the Treatment of Alzheimer's Disease - AFP 11/98
Early Diagnosis of Dementia - AFP 02/01