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A 74-year-old retired auto mechanic presents to clinic with his wife and daughter, who are concerned about his behavior. The patient has become more irritable and spends most of his days watching television instead of going out to his shop to tinker with old lawnmowers, which he used to fix and sell. He has also begun accusing his wife and daughter of stealing or hiding his wallet and keys, which his wife eventually finds somewhere in the house. He still drives the car downtown, but the wife admits not liking to drive with him because he gets angry when she tells him he has taken a wrong turn. When you ask about the patient's memory, his daughter states that it still seems "good, because he can -remember events from a long time ago as if they were yesterday." The patient agrees: "I think I remember as well as you'd expect for a person my age."

  • What additional questions should you ask to better understand the patient's behavioral changes?
  • What additional medical, social, and family history would be important to obtain?
  • Does the report of good long-term memory preclude the diagnosis of dementia?
  • What is the relationship between mood change and memory loss?

Although recall and the speed of cognitive processing decline slightly with normal aging,1 substantial memory loss is abnormal and reflects underlying pathology. While memory loss characteristically is the most prominent feature of early dementia, impairment in other domains of cognitive function, personality changes, or behavioral disturbances may be the earliest symptoms noted by observers. The prevalence of dementia roughly doubles every 5 years after the age of 60, rising from 1% at age 60 to 25% to 30% at age 85.2 Nearly two-thirds of patients age 75 and older with dementia will have Alzheimer's disease.

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DementiaObsolete: senility, organic brain syndromeA decline from a previous state of mental functioning that interferes with social or occupational activities. Dementia involves memory plus at least one of the following: (1) aphasia (language impairment); (2) impairment in executive function (eg, organizing, abstracting, judgment); (3) apraxia (impaired ability to carry out familiar motor tasks despite intact motor function); and (4) agnosia (inability to identify familiar objects or substances despite intact sensation, such as failure to recognize the smell of coffee grounds).
Mild cognitive impairment (MCI)Cognitive impairment—no dementiaA decline from a previous state of mental functioning that causes no or minimal interference with daily activities. MCI is considered a transitional state between normal, age-associated memory impairment and dementia. Multiple definitions exist. It is most commonly classified as amnestic (subjective or objective evidence of memory impairment) or nonamnestic (memory sparing). Amnestic and nonamnestic MCI are further subclassified as involving single or multiple cognitive domains.3
DeliriumAcute confusional stateA state of global cognitive impairment with an acute onset, fluctuating course, short-term memory dysfunction, inattention, and disorganized thinking ...

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