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can cause symptoms of dementia include
anticholinergics, antihypertensives, and
anticonvulsants. Toxic levels of medications can
cause delirium (eg, anticholinergics,
anticonvulsants, antipsychotics, antihypertensives,
steroids, sedatives, hypnotics).
Mental Status Exam
General appearance: Disheveled, angry and
uncooperative, poorly related, inattentive, limited
eye contact, and confused.
Speech: Normal rate, rhythm, and volume in
general, but possibly dysarthric if associated with
cerebrovascular disease.
Mood: Fine, depressed.
Affect: Dysphoric, irritable, and labile with inter
mittent hostility.
Thought process: Illogical, tangential, difficulty
following train of thought, perseverative at times.
Thought content: Paranoid delusions, such as
people stealing from the patient or impersonating
family members, and confabulation.
Perceptual: Auditory, visual, and command
hallucinations are possible.
Suicidality: Varies with level of self-awareness
and presence of psychosis or affective symptoms.
Homicidality: May occur in association with
paranoia.
Sensorium/cognition: Non-delirious, demented
patients should be alert, but may not be oriented
to place or time. Registration and recall may be
impaired; concentration is impaired, word finding
difficulties are common, and apraxia affects ability
to follow commands. On the clock-drawing task,
patients may bunch numbers together, skip num
bers, or indicate the time incorrectly. The mini
mental state score will be less than 24 in de
mented patients.
Impulse control: Limited. Patients have aggres
sive outbursts with difficulty controlling anger.
Judgment: Impaired. Patients are socially inap
propriate and potentially disinhibited.
Insight: Insight is characteristically absent, and
patients tend to minimize symptoms.
Reliability: Impaired. Family members and care
givers should be interviewed for information.
Laboratory data: Complete blood count, chemis
try, toxicology screen, urinalysis, thyroid function
tests, vitamin B12 and folate levels, RPR, thiamine
level, homocysteine level, and HIV testing.
Diagnostic testing: Chest x-ray, computed
tomography, magnetic resonance imaging, Boston
Naming Test (language), Weschler memory scale,
Weschler Adult Intelligence Scale, digit span test
(attention and recall), Wisconsin Card Sorting Test
(executive function), Trail Making A and B (cogni
tive processing speed), Halstead Battery Category
Test (abstraction), Hachinski ischemia score, and
Delirium Rating Scale.
Diagnosis: Axis I: Delirium, dementia, depres
sion (pseudodementia), amnesia.
Differential Diagnosis:
Psychiatric: Amnesia, depression, mania, schizo
phrenia, and normal aging.
Medical: Alzheimer s disease, Lewy Body dis
ease, Pick s disease, Parkinson s disease, Hunting
ton s disease, Wilson s disease, vascular demen
tia, demyelinating disorders, traumatic brain
injuries, cerebral neoplasm, hydrocephalus, CNS
infection, heavy metal poisoning, uremia, hepatic
encephalopathy, hyperthyroidism, hypercalcemia,
vitamin B12 and folate deficiency.
Dementia - Discussion
I. Epidemiology. Alzheimer s disease is respon
sible for approximately half of all cases of
cognitive impairment in the elderly. Vascular
dementia causes 15 to 20 percent cases of
cognitive impairment in the elderly. Alzheimer s
and vascular dementia together account for the
vast majority of dementia cases. However,
dementias, such as Lewy Body disease, Pick s
disease, Parkinson s disease, HIV-related
dementia, and Huntington s disease, should be
considered in the differential diagnosis. Demen
tia affects up to 50 percent of the population
over age 85.
II. Etiology
A. Alzheimer s disease is a result of
neuropathological changes that include
amyloid protein deposition. Approximately
40 percent of all patients have a family
history of the disease.
B. Vascular dementia is caused by multiple
infarctions due to atherosclerotic plaques
and thromboemboli occluding cerebral
vessels.
C. Delirium is associated with medical illness
and surgical procedures. Patients with un
derlying dementia and the elderly are at the
greatest risk of developing delirium.
III.Clinical evaluation
A. The hallmark of dementia is memory loss
(amnesia). Patients may wander in their
neighborhood, pace around their house, and
have difficulties with everyday tasks, such
as dressing or tying shoelaces (apraxia).
They may fail to recognize objects or family
members (agnosia). Language disturbance
can cause word-finding difficulties (aphasia),
and planning and organizational abilities are
often impaired (executive functioning).
B. Alzheimer s disease is more likely than with
other causes of dementia to cause personal
ity changes and aggressive, irritable, sarcas
tic, or apathetic behavior.
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