A 69-year-old patient is brought to the office by his daughter because his behavior has
progressively deteriorated over the past year She states that he initially began having memory
problems several years ago and would frequently forget his grandchildren’s names. He would
frequently have difficulty finding words as well. There have now been several instances lately
where he was found roaming his apartment building, and he was found urinating in the hallway
several days ago. He insists that there is nothing wrong with him, and tries to give excuses for
what his daughter is reporting. His wife died three years ago. He does not feel particularly
fatigued and has a good appetite. He does not smoke, has no history of alcohol abuse, and no
history of diabetes. His blood pressure is 155/85 mm Hg, pulse is 90 /min, and respirations are
15/min. Although the neurologic exam was difficult to assess, there were no abnormalities
found. Plantar reflexes are downgoing bilaterally There is no evidence of rectal or bladder
incontinence. The mini-mental state examination (MMSE) score is 15/30. The laboratory studies
show
Hb
RBC
Hct
Leukocyte count
Platelet count
MCV
MCHC
Calcium
Sodium
Potassium
13.5 g/dl
4.5 million/mm3
45%
4,500/mm3
230,000/mm3
83 um3
32% Hb/cell
9.0 mg/dl
137 mEq/dL
4.0 mEq/dL
MCV
MCHC
Calcium
Sodium
Potassium
Creatinine
Glucose
TSH
Total cholesterol
83 um3
32% Hb/cell
9.0 mg/dl
137 mEq/dL
4.0 mEq/dL
1.1 mg/dl
100 mg/dl
3 uU/mL
180 mg/dl
A CT scan of the brain is performed Which of the following abnormalities might you see on the
CT scan?
0 A Acute subdural hematoma
0 B. Large areas of hypodensity involving different brain regions
0 C. Diffuse cortical and subcortical atrophy which is disproportionately greater in the
temporal and parietal lobes
0 D. Enlargement of the ventricle without cortical atrophy
0 E. Marked atrophy of the frontal and temporal lobes
Explanation:
A MMSE score of less than 24 points is suggestive of dementia (total maximum is
30) Alzheimer’s disease almost exclusively occurs in individuals over the age of 60, and the risk
increases with age The initial symptom in Alzheimer’s is memory loss which progresses over
time. Initially, only short-term memory is affected, but later there is impaired long-term memory
and cognitive abilities, which compromise daily activities and disrupt normal life. Word-finding
difficulty as well as loss of visuospatial skills and executive function are also common
findings Patients typically have a lack of insight into their condition. The disease generally
progresses over a period of years and has a life expectancy of 3-8 years after diagnosis Later
in the course of the disease, patients may experience confusion and disorientation as manifested
by this patient’s wandering and urinating in the hallway of his apartment building
Neuroimaging is typically performed in order to exclude alternative diagnoses such as tumor,
subdural hematoma, or normal pressure hydrocephalus. CT scans on patients with early
Alzheimer’s are typically normal. Cortical and subcortical atrophy is seen in patients with later
stage disease, although this is only mildly greater when compared to age-matched
controls. Atrophy may be more prominent in the parietal and temporal lobes, particularly the
hippocampi
{Choice A) Chronic subdural hematomas are in the differential diagnosis for dementia. However,
this would be unlikely in this patient given the typical progression of findings that are seen in
Alzheimer’s disease.
(Choice B) Multi-infarct dementia is associated with focal neurologic signs and evolves in a
stepwise fashion. Multiple hypodense infarcts may be seen on CT
(Choice D) Normal pressure hydrocephalus (NPH) is characterized by a triad of dementia, gait
disturbance and bladder incontinence. The ventricles are frequently prominent in older patients
from volume loss, however the absence of sulcal enlargement can be helpful in differentiating
NPH from atrophy
(Choice E) The symptoms of frontotemporal dementia are similar to Alzheimer’s, however the age
stage disease, although this is only m’ildly greater when compared to age-matched
controls. Atrophy may be more prominent in the parietal and temporal lobes, particularly the
hippocampi
(Choice A) Chronic subdural hematomas are in the differential diagnosis for dementia. However,
this would be unlikely in this patient given the typical progression of findings that are seen in
Alzheimer’s disease.
(Choice B) Multi-infarct dementia is associated with focal neurologic signs and evolves in a
stepwise fashion. Multiple hypodense infarcts may be seen on CT.
(Choice D) Normal pressure hydrocephalus (NPH) is characterized by a triad of dementia, gait
disturbance and bladder incontinence. The ventricles are frequently prominent in older patients
from volume loss, however the absence of sulcal enlargement can be helpful in differentiating
NPH from atrophy
(Choice E) The symptoms of frontotemporal dementia are similar to Alzheimer’s, however the age
of onset is earlier (usually at 40-60 years) Furthermore, the disease progression is also
different There is initially less disorientation and memory loss, but more personality changes and
loss of social restraints. Eventually, patients exhibit profound dementia and become mute,
immobile, and incontinent Marked atrophy of the frontal and temporal lobes may be seen on
CT. This patient’s urinating in the hallway is likely a manifestation of confusion from late stage
Alzheimer’s as opposed to social disinhibition.
Educational objective:
A MMSE score of less than 24 points is suggestive of dementia (total maximum is
30). Alzheimer’s disease presents initially with memory symptoms, with symptoms that progress
over a period of years Social disinhibition and personality changes are the early features in
frontotemporal dementia. Neuroimaging may demonstrate atrophy which is more prominent in the
temporal and parietal lobes in patients with Alzheimer’s disease, although imaging should primarily
be used to exclude alternative causes for dementia as opposed to making a diagnosis of
Alzheimer’s.
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