Review Question - QID 217635

This patient presents with occasional word- and name-finding difficulty, forgetfulness, and insomnia, while still maintaining independent activities of daily living (ADLs). These are normal, age-related changes.

Patients presenting with progressive decline in memory and other cognitive domains should be evaluated for dementia, which should be differentiated from normal aging. Changes in normal aging are typically mild and do not cause impairment in independent ADLs. In normal aging, patients can report occasional forgetfulness, word-finding challenges, cognitive slowing, difficulty falling asleep, and waking up earlier. Procedural and semantic memory are preserved. In dementia, these symptoms are more severe, such as forgetting the names of family or close friends and misplacing objects in strange locations (keys in the refrigerator). In dementia, symptoms must cause a loss of independence in ADLs. Standardized cognitive assessments such as the Montreal Cognitive Assessment can be used to aid in the diagnosis, although the diagnosis is primarily clinical. In patients with suspected dementia, an MRI of the brain can rule out alternative causes and may demonstrate classic findings including advanced atrophy.

Jutten et al. performed a study to evaluate the performance of the Amsterdam independent ADL Questionnaire (short version) in distinguishing normal aging from dementia. They found that this survey exhibited good concordance with other metrics. They recommend using the short-form versions as a concise summary of functional decline.

Incorrect Answers:
Answer 1: Alzheimer dementia presents with a marked anterograde long-term episodic amnesia as well as some impairment in executive function. Patients may ask the same questions repeatedly or forget the names of close friends and family. Notably, patients must have impairment of ADLs for a diagnosis of dementia to be made. This patient’s symptoms are less severe and do not cause functional impairment. Symptomatic treatment with acetylcholinesterase inhibitors may improve symptoms.

Answer 2: Frontotemporal dementia is characterized by marked impairment in executive function, presenting as disinhibition, apathy, hyperorality, and compulsive behaviors (gambling). This patient does not have severe impairment in executive function. There is no specific treatment for this condition.

Answer 4: Pseudodementia refers to the cognitive impairment that often occurs secondary to major depression. While all patients with cognitive impairment should be screened for depression, this patient does not satisfy the criteria for major depression and does not have prominent mood symptoms. Though she does not spend as much time with friends, this seems to be a deliberate choice rather than social withdrawal. Treatment of pseudodementia is by treating the underlying psychiatric disorder.

Answer 5: Vascular dementia is characterized by a stepwise decline in cognitive function caused by progressive cerebral infarcts. Presenting signs depend on the brain areas affected, which could include cognitive deficits, language impairments, and/or executive dysfunction. This patient’s symptoms do not fit a stepwise pattern. Treatment is through the control of vascular risk factors such as hypertension (the most common risk factor) to prevent further decline.

Bullet Summary:
Normal aging is characterized by occasional forgetfulness, word-finding difficulties, and insomnia, but executive function and activities of daily living are generally preserved.