CASE PRESENTATIONCASE PRESENTATION

Dr. LU, QINCHIDr. LU, QINCHI DEPARTMENT OF NEUROLOGYDEPARTMENT OF NEUROLOGY

REN JI HOSPITALREN JI HOSPITAL

SHANGHAI JIAO TONG UNIVERSITYSHANGHAI JIAO TONG UNIVERSITY

SCHOOL OF MEDICINESCHOOL OF MEDICINE Tel: 58752345-3094Tel: 58752345-3094

Email: qinchilu@hotmail.comEmail: qinchilu@hotmail.com

HistoryHistory

A 68-year-old woman has been noted by her A 68-year-old woman has been noted by her daughter to have memory loss and confusion. daughter to have memory loss and confusion. The daughter states that her mother has been The daughter states that her mother has been going “downhill” for the past several months. going “downhill” for the past several months. The mother has lived on her own for many The mother has lived on her own for many years ,but recently she has begun to become years ,but recently she has begun to become unable to take care of herself. unable to take care of herself.

HistoryHistory

The daughter states that her mother has The daughter states that her mother has become withdrawn and has lost interest in her become withdrawn and has lost interest in her usual activities, such as gardening and reading. usual activities, such as gardening and reading. Her mother’s memory is poor, and she is often Her mother’s memory is poor, and she is often fatigued. The patient states that she sleeps well fatigued. The patient states that she sleeps well at night and that her appetite is good, although at night and that her appetite is good, although she has lost 10 lb over the past 6 months. She she has lost 10 lb over the past 6 months. She denies bowel and urinary incontinence. denies bowel and urinary incontinence.

HistoryHistory

The patient’s past medical history is significant The patient’s past medical history is significant for hypertension for which she has been taking for hypertension for which she has been taking hydrochlorethiazide. The patient was last hospihydrochlorethiazide. The patient was last hospitalized 35 years ago when she underwent a totatalized 35 years ago when she underwent a total abdominal hysterectomy with bilateral salpinl abdominal hysterectomy with bilateral salpingo-oophorectomy. The patient has enjoyed ovego-oophorectomy. The patient has enjoyed overall good health. She does not smoke or drink. rall good health. She does not smoke or drink.

Physical ExamPhysical Exam

On examination, her blood pressure is 116/56 On examination, her blood pressure is 116/56 mmHg, her heart rate is 78 bpm, her temperatummHg, her heart rate is 78 bpm, her temperature is 37.5re is 37.5 。。C, and her respiratory rate is 18 breC, and her respiratory rate is 18 breaths per minute. She weighs 88 kg and her heiaths per minute. She weighs 88 kg and her height is 1.62m. The patient is a well-developed ght is 1.62m. The patient is a well-developed white women with a flat affect. She is oriented white women with a flat affect. She is oriented to person, but she is not oriented to time and plto person, but she is not oriented to time and place. ace.

Pyhsical & Neuro ExamPyhsical & Neuro Exam

Mini Mental Status ExaminationMini Mental Status Examination gives a score of 1 gives a score of 18 out of 30. The head and neck and cardiovascular ex8 out of 30. The head and neck and cardiovascular examination are unremarkable. Abdomen is benign withamination are unremarkable. Abdomen is benign without hepatosplenomegaly. The extremities are without out hepatosplenomegaly. The extremities are without edema, cyanosis, or clubbing. The neurologic examinedema, cyanosis, or clubbing. The neurologic examination reveals that the cranial nerves are intact, and the ation reveals that the cranial nerves are intact, and the motor and sensory exams are within normal limits. Cmotor and sensory exams are within normal limits. Cerebellum examination is unremarkable and the gait ierebellum examination is unremarkable and the gait is normal.s normal.

QuestionsQuestions

What is the most likely diagnosis?What is the most likely diagnosis? What are the next diagnostic steps?What are the next diagnostic steps? What is the best treatment for this condition?What is the best treatment for this condition?

Summary: Summary:

A 68-year-old woman has memory loss, A 68-year-old woman has memory loss, confusion, and fatigue, and is withdrawn. She confusion, and fatigue, and is withdrawn. She had a flat affect. She is oriented to person, but had a flat affect. She is oriented to person, but she is not oriented to time and place. The she is not oriented to time and place. The remainder of the examination, including remainder of the examination, including neurological examination, is normal except for neurological examination, is normal except for a low score on the MMSE.a low score on the MMSE.

Most likely diagnosis: Most likely diagnosis:

Alzheimer dementia. Alzheimer dementia.

Next diagnostic step: Next diagnostic step:

Assess for depression Assess for depression and reversible causes and reversible causes of dementia.of dementia.

Probable treatment: Probable treatment:

Acetylcholinesterase inAcetylcholinesterase inhibitor hibitor

AnalysisAnalysis

ObjectivesObjectives

Know some of the common causes of demenKnow some of the common causes of dementiatia

Understand the presentation and diagnosis of Understand the presentation and diagnosis of Alzheimer dementiaAlzheimer dementia

Know the treatment for Alzheimer dementia Know the treatment for Alzheimer dementia is acetylcholinesterase inhibitoris acetylcholinesterase inhibitor

ConsiderationsConsiderations

This is an elderly woman without any This is an elderly woman without any significant past medical history except for significant past medical history except for hypertension who was brought to your office hypertension who was brought to your office with a history of progressive functional decline with a history of progressive functional decline and memory loss. The first step should be to and memory loss. The first step should be to rule out depression. Depression in the elderly rule out depression. Depression in the elderly may have a presentation very similar to that of may have a presentation very similar to that of dementia with withdrawal, apathy, irritability, dementia with withdrawal, apathy, irritability, memory impairment, and confusion. memory impairment, and confusion.

ConsiderationsConsiderations

The next step should be to rule out all the possiThe next step should be to rule out all the possible causes of reversible or arrestable dementia, ble causes of reversible or arrestable dementia, such as multi-infarct dementia, hypothyroidissuch as multi-infarct dementia, hypothyroidism, drugs, Bm, drugs, B1212 deficiency, normal pressure hydr deficiency, normal pressure hydr

ocephalus, alcoholism, HIV, and syphilis. ocephalus, alcoholism, HIV, and syphilis.

ConsiderationsConsiderations

Laboratory tests will help you to eliminate Laboratory tests will help you to eliminate some of these common causes of reversible some of these common causes of reversible dementia: complete blood count (CBC), dementia: complete blood count (CBC), comprehensive metabolic panel, thyroid-comprehensive metabolic panel, thyroid-stimulating hormone (TSH), urinalysis, stimulating hormone (TSH), urinalysis, serologic test for syphilis, and a head CT (see serologic test for syphilis, and a head CT (see table 49-1). table 49-1).

Table 49-1Table 49-1ABBREVIATED WORKUP FOR DEMENTIAABBREVIATED WORKUP FOR DEMENTIA

Complete blood count and consider erythrocyte Complete blood count and consider erythrocyte sedimentation rate (ESR) sedimentation rate (ESR)

Chemistry panel Chemistry panel

Thyroid-stimulating hormone level Thyroid-stimulating hormone level

Venereal Disease Research Laboratory (VDRL) Venereal Disease Research Laboratory (VDRL)

HIV assay HIV assay

Urinalysis Urinalysis

Serum vitamin B12 and folate levels Serum vitamin B12 and folate levels

Chest radiographChest radiograph

Electrocardiogram Electrocardiogram

CT or MRI imaging of the head CT or MRI imaging of the head

ConsiderationsConsiderations

The possibility of HIV-induced dementia is not The possibility of HIV-induced dementia is not high on the differential in this case given the phigh on the differential in this case given the patient’s age, but it would certainly be a consideatient’s age, but it would certainly be a consideration in younger people. Possible infectious cration in younger people. Possible infectious causes of reversible dementia include not only auses of reversible dementia include not only HIV but also neurosyphilis. Therefore, a seroloHIV but also neurosyphilis. Therefore, a serologic test for syphilis is indicated. gic test for syphilis is indicated.

ConsiderationsConsiderations

Because our patient does not have a history of Because our patient does not have a history of chronic alcoholism, we can rule out this chronic alcoholism, we can rule out this condition. The CBC and mean cell volume condition. The CBC and mean cell volume (MCV) are normal, as is the TSH, eliminating (MCV) are normal, as is the TSH, eliminating the possibilities of vitamin Bthe possibilities of vitamin B12 12 deficiency and deficiency and of hypothyroidism. The patient is only taking of hypothyroidism. The patient is only taking hydrochlorothiazide, which is not associated hydrochlorothiazide, which is not associated with the described mental status changes. A with the described mental status changes. A CT head scan can assess for brain lesions, CT head scan can assess for brain lesions, multiple infarcts, and hydrocephalus. multiple infarcts, and hydrocephalus.

ConsiderationsConsiderations

Therefore, in this case we are left with the possTherefore, in this case we are left with the possibility of multi-infarct dementia and Alzheimer ibility of multi-infarct dementia and Alzheimer disease. Multi-infarct dementia develops later idisease. Multi-infarct dementia develops later in life and is caused by diffuse cerebrovascular n life and is caused by diffuse cerebrovascular disease. Most of the patients will have a histordisease. Most of the patients will have a history of transient ischemic attacks and strokes, and y of transient ischemic attacks and strokes, and stepwise progression of dementia which our pastepwise progression of dementia which our patient does not report. In this particular case, Altient does not report. In this particular case, Alzheimer dementia becomes the most likely diazheimer dementia becomes the most likely diagnosis.gnosis.

APPROACH APPROACH TO TO

DEMENTIADEMENTIA

DefinitionsDefinitions

Alzheimer disease: The leading cause of Alzheimer disease: The leading cause of dementia, accounting for half of the cases dementia, accounting for half of the cases involving elderly individuals, correlating to involving elderly individuals, correlating to brain atrophy with ventricular enlargement.brain atrophy with ventricular enlargement.

Dementia: Progressive and generalized decline Dementia: Progressive and generalized decline of intellectual ability from a previously of intellectual ability from a previously attained level, usually without alteration of attained level, usually without alteration of consciousness. consciousness.

DefinitionsDefinitions

Multiinfarct dementia: Numerous small cerebral vascMultiinfarct dementia: Numerous small cerebral vascular accidents, most commonly caused by atherosclerular accidents, most commonly caused by atherosclerotic disease, leading to dementia.otic disease, leading to dementia.

Normal pressure hydrocephalus: Reversible form of dNormal pressure hydrocephalus: Reversible form of dementia where the cerebral ventricles slowly enlarge ementia where the cerebral ventricles slowly enlarge as a result of disturbances to cerebral spinal fluid resoas a result of disturbances to cerebral spinal fluid resorption. The classic triad is dementia, gait disturbance, rption. The classic triad is dementia, gait disturbance, and urinary or bowel incontinence.and urinary or bowel incontinence.

Clinical ApproachClinical Approach

A patient who presents with memory and A patient who presents with memory and functional impairment should be approached functional impairment should be approached from the perspective that many etiologies can from the perspective that many etiologies can be causative. A thorough description of the be causative. A thorough description of the patient’s cognitive, adaptive, memory, and patient’s cognitive, adaptive, memory, and behavioral ability over time is critical. behavioral ability over time is critical. Multiple family members are often needed to Multiple family members are often needed to construct a complete and accurate picture. The construct a complete and accurate picture. The time frame (months to years versus days to time frame (months to years versus days to weeks) is important. weeks) is important.

Clinical ApproachClinical Approach

A history of head trauma, neurological A history of head trauma, neurological symptoms, a stepwise decline (multi-infarct symptoms, a stepwise decline (multi-infarct dementia) versus a insidious gradual decline dementia) versus a insidious gradual decline may be helpful. A record of all medications, may be helpful. A record of all medications, habits, alcohol use (even remote), can habits, alcohol use (even remote), can potentially cause mental status changes in the potentially cause mental status changes in the elderly. A resting tremor of Parkinson disease, elderly. A resting tremor of Parkinson disease, cold intolerance suggestive of hypothyroidism, cold intolerance suggestive of hypothyroidism, or vitamin deficiencies may be helpful.or vitamin deficiencies may be helpful.

Clinical ApproachClinical Approach

The other intracranial diseases that could cause The other intracranial diseases that could cause a dementia-like picture include subdural hemata dementia-like picture include subdural hematoma and normal pressure hydrocephalus. Usuaoma and normal pressure hydrocephalus. Usually, a CAT (computed axial tomography) scan lly, a CAT (computed axial tomography) scan will allow you to rule out these disease processwill allow you to rule out these disease processes. Also, remember, that normal pressure hydres. Also, remember, that normal pressure hydrocephalus is usually accompanied by gait distuocephalus is usually accompanied by gait disturbances and urinary incontinence which our parbances and urinary incontinence which our patient does not have. tient does not have.

Clinical ApproachClinical Approach

Parkinson disease is also associated with the Parkinson disease is also associated with the development of dementia but patients with development of dementia but patients with Parkinson disease have symptoms and Parkinson disease have symptoms and physical findings that will alert you to the physical findings that will alert you to the diagnosis. Table 49-2 lists the neurological diagnosis. Table 49-2 lists the neurological diseases that impair cognitive ability. diseases that impair cognitive ability.

Table 49-2Table 49-2NEUROLOGICAL DISEASES IMPAIRING COGNITIVE ABILITYNEUROLOGICAL DISEASES IMPAIRING COGNITIVE ABILITY

DISEASE DISEASE CLINICAL FEATURES CLINICAL FEATURES TREATMENT TREATMENT

Alzheimer disease Alzheimer disease Slow decline in cognitive and beSlow decline in cognitive and behavioral ability; pathology: neurhavioral ability; pathology: neurofibrillary tangles, enlarged cereofibrillary tangles, enlarged cerebral ventricles, and atrophy bral ventricles, and atrophy

Cholinesterase inhibitors such Cholinesterase inhibitors such as donepezil or rivastigmine as donepezil or rivastigmine

Normal-pressure Normal-pressure hydrocephalus hydrocephalus

Gate disturbance, dementia, incoGate disturbance, dementia, incontinence; enlarged ventricles witntinence; enlarged ventricles without atrophy hout atrophy

Ventricular shunting process Ventricular shunting process

Multi-infarct Multi-infarct dementia dementia

Focal deficits, stepwise loss of fuFocal deficits, stepwise loss of function; multiple areas of infarct nction; multiple areas of infarct usually subcortical usually subcortical

Address atherosclerotic risk Address atherosclerotic risk factors, identify and treat factors, identify and treat thrombus thrombus

Parkinson disease Parkinson disease Extrapyramidal signs (tremor, riExtrapyramidal signs (tremor, rigidity), slow onset gidity), slow onset

Dopaminergic agents Dopaminergic agents

Table 49-2 (cont)Table 49-2 (cont)NEUROLOGICAL DISEASES IMPAIRING COGNITIVE ABILITYNEUROLOGICAL DISEASES IMPAIRING COGNITIVE ABILITY

DISEASE DISEASE CLINICAL FEATURES CLINICAL FEATURES TREATMENT TREATMENT

HIV defintion HIV defintion Systemic involvement; risk factors Systemic involvement; risk factors for acquisition; positive HIV for acquisition; positive HIV serology serology

Treat specific infection Treat specific infection

Neurosyphilis Neurosyphilis Optic atrophy, Argyll-Robertson pOptic atrophy, Argyll-Robertson pupils, gait disturbance; positive ceupils, gait disturbance; positive cerebro-spinal fluid serology rebro-spinal fluid serology

High dose intravenous High dose intravenous penicillinpenicillin

Multiple sclerosis Multiple sclerosis Brainstem signs, optic atrophy, Brainstem signs, optic atrophy, long-standing disease with long-standing disease with exacerbations and remissions; exacerbations and remissions; MRI showing white matter MRI showing white matter abnormalities abnormalities

Recombinant interferon, Recombinant interferon, corticosteroids corticosteroids

Intracranial tumor Intracranial tumor Focal signs, papilledema, seizures Focal signs, papilledema, seizures Corticosteroids to reduce Corticosteroids to reduce intracranial pressure, treat intracranial pressure, treat the lesion the lesion

Clinical ApproachClinical Approach

The etiology of Alzheimer dementia is an unknown buThe etiology of Alzheimer dementia is an unknown but Alzheimer disease has a genetic component. The rist Alzheimer disease has a genetic component. The risk of developing the disease for an individual in a famik of developing the disease for an individual in a family with Alzheimer disease increases by a factor of 3 oly with Alzheimer disease increases by a factor of 3 or 4. The gene that codes for apoprotein E seems to be r 4. The gene that codes for apoprotein E seems to be associated with some prediction. The pathologic chanassociated with some prediction. The pathologic changes in the brains of Alzheimer disease patients includges in the brains of Alzheimer disease patients include neurofibrillary tangles with a deposition of abnormae neurofibrillary tangles with a deposition of abnormal amyloid in the brain. l amyloid in the brain.

Amyloid Precursor Protein

A-ß

Neurofibrillary Tangles

A-ß Aggregation

Neuron Death

Basal Forebrain and Brainstem

Nuclei

Neurotransmitter Deficits

Neuritic Plaques

Neuron Death

Cortex

Demantia Syndrome

Mutations and vulnerability genes associated Mutations and vulnerability genes associated with Alzheimer’s diseasewith Alzheimer’s disease

Genotype Cellular effect

Mutations

Down syndrome(trisomy 21)

Increased APP productionwith enhanced generationof Aβ

APP mutations(varions)

21q21.1-21.3

Altered APP processingresultiong in increasedproduction of Aβ

Chromosome 14 (PS1mutation)

14q24.2-24.3

Increased Aβ production

Chromosome 1 (PS2mutation)

1q31-32

Increased Aβ production

Mutations and vulnerability genes associated with Mutations and vulnerability genes associated with Alzheimer’s diseaseAlzheimer’s disease

Genetic risk factorsChromosome 19 (ApoE-4) 19q13.2

Increase Aβ aggregation

Chromosome 12 (low-densitylipoprotein receptor-relatedprotein)

Lipoprotein receptormediating the moleculareffects of ApoE-4

Chromosome 6 (HLA-A2) HLA histocompatibilityallele regulating theinflammatory response

Chromosome 17 Bleomycin hydrolase;implicated in APPprocessing

Classical neuritic plaqueClassical neuritic plaque(Bielschowsky silver stain)(Bielschowsky silver stain)

Neurofibrillary Tangles

Neurofibrillary tanglesNeurofibrillary tangles(H&E stain)(H&E stain)

Cerebral amyloid angiopathyCerebral amyloid angiopathy(H&E stain)(H&E stain)

Clinical ApproachClinical Approach

The disease onset can be very insidious and the The disease onset can be very insidious and the average life expectancy after diagnosis is 7-10 average life expectancy after diagnosis is 7-10 years. The clinical course is characterized by years. The clinical course is characterized by the progressive decline of cognitive functions the progressive decline of cognitive functions (memory, orientation, attention and (memory, orientation, attention and concentration) and the development of concentration) and the development of psychological and behavioral symptoms psychological and behavioral symptoms (wandering, aggression, anxiety, depression (wandering, aggression, anxiety, depression and psychosis) (see Table 49-3)and psychosis) (see Table 49-3)

Table 49-3Table 49-3ALZHEIMER DISEASE CLINICAL COURSEALZHEIMER DISEASE CLINICAL COURSE

CLINICAL STAGECLINICAL STAGE MANIFESTATIONS MANIFESTATIONS

Early Early Mild forgetfulness, poor concentration, fairly good Mild forgetfulness, poor concentration, fairly good function, denial, occasional disorientation function, denial, occasional disorientation

Intermediate Intermediate Drastic deficits for recent memory, can travel to Drastic deficits for recent memory, can travel to familiar locations, suspicious, anxious, aware of familiar locations, suspicious, anxious, aware of confusion confusion

Late Late Cannot remember names of family members or close Cannot remember names of family members or close friends; may have delusions or hallucinations, agitation, friends; may have delusions or hallucinations, agitation, aggression, wandering, disoriented to time and place, aggression, wandering, disoriented to time and place, need for substantial care need for substantial care

AdvancedAdvanced Totally incapacitated and disoriented, incontinent, Totally incapacitated and disoriented, incontinent, personality and emotional changes; eventually all personality and emotional changes; eventually all verbal and motor skills deteriorate, leading to need for verbal and motor skills deteriorate, leading to need for total care total care

TreatmentTreatment

The goals of treatment in Alzheimer disease The goals of treatment in Alzheimer disease are to are to

(a) improve cognitive function(a) improve cognitive function

(b) reduce behavioral and psychological (b) reduce behavioral and psychological symptoms, and symptoms, and

(c) improve the quality of life. (c) improve the quality of life.

TreatmentTreatment Donepezil (Aricept) and revastigmine (Exelon) are chDonepezil (Aricept) and revastigmine (Exelon) are ch

olinesterase inhibitors that are effective in improving olinesterase inhibitors that are effective in improving cognitive function and global clinical state.cognitive function and global clinical state.

Memantine ( Namenda) is the only NMDA receptor Memantine ( Namenda) is the only NMDA receptor antagonist for moderate to severe Alzheimer dementiantagonist for moderate to severe Alzheimer dementiaa

Risperidone reduces psychotic symptoms and aggressRisperidone reduces psychotic symptoms and aggression in patients with dementia. ion in patients with dementia.

TreatmentTreatment

Other issues include wakefulness, nightwalkinOther issues include wakefulness, nightwalking and wandering, aggression, incontinence, ang and wandering, aggression, incontinence, and depression. A structured environment, with pd depression. A structured environment, with predictability, and judicious use of pharmacotheredictability, and judicious use of pharmacotherapy, such as selective serotonin reuptake inhirapy, such as selective serotonin reuptake inhibitor (SSRI) for depression or short-acting benbitor (SSRI) for depression or short-acting benzodiazepine for insomnia, are helpful. zodiazepine for insomnia, are helpful.

Opportunities for treatment of ADOpportunities for treatment of AD

Enhancement of cholinergic functionEnhancement of cholinergic function Cholinesterase inhibitorsCholinesterase inhibitors

TacrineTacrine Donepezil (Aricept)Donepezil (Aricept) Rivastigmine ( Exelon)Rivastigmine ( Exelon) Huperzine AHuperzine A

Cholinesterase receptor agonistsCholinesterase receptor agonists NMDA receptor antagonistNMDA receptor antagonist

Memantine( Namenda)Memantine( Namenda)

TreatmentTreatment

The primary caregiver is a often overwhelmed The primary caregiver is a often overwhelmed and needs support. The Alzheimer Association and needs support. The Alzheimer Association is a national organization developed to give suis a national organization developed to give support to family members, and can be contacted pport to family members, and can be contacted through through www.alz.orgwww.alz.org..

Comprehension Comprehension QuestionsQuestions

[1] A 78-year-old female is diagnosed with Alzh[1] A 78-year-old female is diagnosed with Alzheimer disease. Which of the following agents ieimer disease. Which of the following agents is most likely to help with the cognitive functios most likely to help with the cognitive function?n?

A. HaloperidolA. Haloperidol B. Estrogen replacement therapyB. Estrogen replacement therapy C. DonepezilC. Donepezil D. High dose Vitamin BD. High dose Vitamin B1212 injections injections

ANSWERANSWER

[1] C. Cholinesterase inhibitors help with the [1] C. Cholinesterase inhibitors help with the cognitive function in Alzheimer disease and cognitive function in Alzheimer disease and may slow the progression somewhat.may slow the progression somewhat.

[2] A 74-year-old male was noted to have excellent [2] A 74-year-old male was noted to have excellent cognitive and motor skill 12 months ago. His wife cognitive and motor skill 12 months ago. His wife noted that 6 months ago, his function deteriorated in a noted that 6 months ago, his function deteriorated in a noticeable way, and, again, 2 months ago, another noticeable way, and, again, 2 months ago, another level of deterioration was noted. Which of the level of deterioration was noted. Which of the following is most likely to reveal the etiology of his following is most likely to reveal the etiology of his functional decline?functional decline?

A. HIV Antibody testA. HIV Antibody test B. Magnetic resonance imaging of the brainB. Magnetic resonance imaging of the brain C. Cerebrospinal fluid VDRL testC. Cerebrospinal fluid VDRL test D. Serum thyroid-stimulating hormone (TSH)D. Serum thyroid-stimulating hormone (TSH)

ANSWERANSWER

[2] B. The stepwise decline in function is [2] B. The stepwise decline in function is typical for multi-infarct dementia, diagnosed typical for multi-infarct dementia, diagnosed by viewing multiple areas of the brain infarct.by viewing multiple areas of the brain infarct.

[3] A 55-year-old man is noted by his family members [3] A 55-year-old man is noted by his family members to be forgetful and become disoriented. He also has dito be forgetful and become disoriented. He also has difficulty making it to the bathroom in time, and complfficulty making it to the bathroom in time, and complains of feeling as though “he is walking like he was dains of feeling as though “he is walking like he was drunk”. Which therapy is most likely to improve his corunk”. Which therapy is most likely to improve his condition?ndition?

A. Intravenous penicillin for 21 daysA. Intravenous penicillin for 21 days B. RivastigmineB. Rivastigmine C. Treatment with fluoxetine for 9 to 12 months\C. Treatment with fluoxetine for 9 to 12 months\ D. Ventriculoperitoneal shunt D. Ventriculoperitoneal shunt E. Enrollment into Alcoholic AnonymousE. Enrollment into Alcoholic Anonymous

ANSWERANSWER

[3] D. The classic triad for normal pressure [3] D. The classic triad for normal pressure hydrocephalus is dementia, incontinence, and hydrocephalus is dementia, incontinence, and gait disturbance; one treatment is shunting the gait disturbance; one treatment is shunting the cerebrospinal fluid. cerebrospinal fluid.

[4] Which of the following commonly seen in brain [4] Which of the following commonly seen in brain imaging of patients with Alzheimer disease?imaging of patients with Alzheimer disease?

A. Normal cerebral ventricles and atrophic brain A. Normal cerebral ventricles and atrophic brain tissuetissue

B. Enlarged cerebral ventricles and atrophic brain B. Enlarged cerebral ventricles and atrophic brain tissuetissue

C. Enlarged cerebral ventricles and no atrophy of C. Enlarged cerebral ventricles and no atrophy of brain tissuebrain tissue

D. Normal cerebral ventricles and normal brain D. Normal cerebral ventricles and normal brain tissue, acetylcholine deficiencytissue, acetylcholine deficiency

ANSWERANSWER

[4] B. Alzheimer disease typically has enlarged [4] B. Alzheimer disease typically has enlarged cerebral ventricles and brain atrophy, whereas cerebral ventricles and brain atrophy, whereas normal pressure hydrocephalus has enlarged normal pressure hydrocephalus has enlarged brain ventricles without brain atrophy.brain ventricles without brain atrophy.

CLINICAL PEARLS CLINICAL PEARLS

Alzheimer disease is the most common type of Alzheimer disease is the most common type of dementia, followed by multi-infarct (arterioscldementia, followed by multi-infarct (arteriosclerotic) dememtia.erotic) dememtia.

Approximately 5% of people older than age of Approximately 5% of people older than age of 65 years and 20% older than age 80 years have 65 years and 20% older than age 80 years have some form of dementia.some form of dementia.

CLINICAL PEARLS CLINICAL PEARLS

Depression and reversible causes of dementia sDepression and reversible causes of dementia should be considered in the evaluation of a patihould be considered in the evaluation of a patient with memory loss and functional decline.ent with memory loss and functional decline.

A cholinesterase inhibitor such as donepezil is A cholinesterase inhibitor such as donepezil is effective in improving cognitive function and effective in improving cognitive function and global clinical state in patients with Alzheimer global clinical state in patients with Alzheimer disease.disease.

THANKS!THANKS!