Question
76-year-old man is brought to the physician by his daughter because of increasing forgetfulness over the past 5 weeks. He had been living independently but came to live with his daughter temporarily after he complained that he was unable to perform some of his daily activities. He has left the front door wide open and tap water running on multiple occasions. He does not sleep well and wakes up 6–7 times during the night. He does not leave his room and rarely makes conversation with his daughter. He says that he used to enjoy playing the piano but has not played for several months. He has hypertension treated with amlodipine. Vital signs are within normal limits. Mental status examination shows orientation to person, place, and time and psychomotor retardation. He has a blunted affect. Short- and long-term memory is impaired. Attention and concentration are impaired. Neurologic examination shows no focal findings. Serum concentration of electrolytes, thyroid-stimulating hormone, and vitamin B12 are within the reference range. He is very concerned about his memory lapses. Which of the following is the most appropriate treatment for this patient?
| A. |
Donepezil
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| B. |
Fluoxetine
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| C. |
Aspirin
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| D. |
Ventriculoperitoneal shunt
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Show Answer
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Correct Answer � B
Explanation
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Fluoxetine
Donepezil
Donepezil is indicated in patients with mild to moderate Alzheimer’s dementia (AD). Patients with AD can present with impairment of daily life and, especially in early stages, show symptoms of depression, making it a differential diagnosis that should be considered. However, the onset of AD is usually insidious, with progression over ~ 8–10 years. The memory of recent events is typically the cognitive domain affected first in patients with AD. For this reason, patients are typically not oriented to person, place, or time. Also, unlike this patient who complains about his memory loss, patients with AD are often not aware of their cognitive deficits.
Fluoxetine
Especially in elderly patients with major depressive disorder, cognitive deficits may resemble dementia. In contrast to other types of dementia, patients with pseudodementia present with impaired memory, which they are typically aware of and readily complain about, in addition to symptoms of major depressive disorder, such as sleep disturbance, psychomotor retardation, and impaired concentration. As in this patient, the cognitive deficits typically manifest after the mood symptoms (e.g., he lost interest in playing the piano several months ago). Treatment of the underlying depression, e.g., with SSRIs such as fluoxetine, may lead to remission of the depression and reversal of the cognitive deficits. In elderly patients, major depressive disorder and dementia may be present at the same time. If memory impairment persists after appropriate treatment and improvement of depressive symptoms, a different cause of dementia must be considered.
Aspirin
Antiplatelet drugs such as aspirin may be considered in patients with vascular dementia. This type of dementia may present with abrupt cognitive decline and stepwise deterioration. This patient has risk factors for vascular dementia such as hypertension and advanced age. However, his loss of interest, sleep disturbance, and psychomotor retardation cannot be explained by this diagnosis and warrant a different treatment.
Ventriculoperitoneal shunt
A cerebral shunt is the treatment of choice for normal pressure hydrocephalus (NPH). While NPH typically presents with impaired memory, other typical findings such as incontinence and ataxic gait are absent in this patient.
