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INTRODUCTION

Dementia

Dementia is an acquired deterioration in cognitive ability that impairs the successful performance of activities of daily living. Memory is the most common cognitive ability lost with dementia; 10% of persons over age 70 and 20–40% of individuals over age 85 have clinically identifiable memory loss. Other mental faculties are also affected in dementia, such as language, visuospatial ability, calculation, judgment, and problem solving. Neuropsychiatric and social deficits develop in many dementia syndromes, resulting in depression, withdrawal, hallucinations, delusions, agitation, insomnia, and disinhibition. Dementia is usually chronic and progressive.

Diagnosis

Brief screening tools such as the Mini-Mental State Examination (MMSE), the Montreal Cognitive Assessment (MOCA), and the Cognistat are useful screening tests and can follow progression. A functional assessment should also be performed to help determine the day-to-day impact of the disorder.

APPROACH TO THE PATIENT: Dementia

Differential Diagnosis: Dementia has many causes (Table 182-1). It is essential to exclude treatable etiologies; the most common potentially reversible diagnoses are depression, hydrocephalus, and alcohol dependence. The major degenerative dementias can usually be distinguished by distinctive symptoms, signs, and neuroimaging features (Table 182-2).

History: A subacute onset of confusion may represent delirium and should trigger the search for intoxication, infection, or metabolic derangement (Chap. 16). An elderly person with slowly progressive memory loss over several years is likely to have Alzheimer’s disease (AD). A change in personality, disinhibition, gain of weight, or compulsive eating suggests frontotemporal dementia (FTD), not AD; apathy, loss of executive function, progressive abnormalities in speech, or relative sparing of memory or visuospatial abilities also suggests FTD. Dementia with Lewy bodies (DLB) is suggested by the early presence of visual hallucinations, parkinsonism, tendency to delirium, sensitivity to psychoactive medications, or a REM behavior disorder (RBD, the loss of skeletal muscle paralysis during dreaming).

A history of stroke suggests vascular dementia, which may also occur with hypertension, atrial fibrillation, peripheral vascular disease, and diabetes. Rapid progression of dementia with myoclonus suggests a prion disease such as Creutzfeldt-Jakob disease (CJD). A rapidly progressive dementia with psychiatric symptoms and seizures suggests paraneoplastic encephalitis associated with NMDA receptor antibodies; affected pts are often young women with ovarian teratoma. Gait disturbance is prominent with vascular dementia, Parkinson’s disease, DLB, or normal-pressure hydrocephalus. Multiple sex partners or IV drug use should trigger search for an infection, especially HIV or syphilis. A history of head trauma could indicate chronic subdural hematoma, chronic traumatic encephalopathy, or normal-pressure hydrocephalus. Alcoholism may suggest malnutrition and thiamine deficiency. A history of gastric surgery may result in loss of intrinsic factor and vitamin B12 deficiency. A careful review of medications, especially of sedatives and tranquilizers, may raise the issue of drug intoxication. A family history of dementia is found in Huntington’s disease and in familial forms of AD, FTD, DLB, or prion disorders. Insomnia or weight loss is ...

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