Behavioral management in dementia US Medical PG Practice Questions and MCQs
Practice US Medical PG questions for Behavioral management in dementia. These multiple choice questions (MCQs) cover important concepts and help you prepare for your exams.
Behavioral management in dementia US Medical PG Question 1: A 70-year-old man with a history of Alzheimer dementia presents to the emergency department with a change in his behavior. The patient has been more confused recently and had a fever. Upon presentation, he is too confused to answer questions. His temperature is 103°F (39.4°C), blood pressure is 102/68 mmHg, pulse is 157/min, respirations are 22/min, and oxygen saturation is 99% on room air. The patient is given 3 liters of IV fluids and acetaminophen and his vitals improve. He is also less confused. The patient is asking where he is and becomes combative and strikes a nurse when he finds out he has to be admitted to the hospital. He is given diphenhydramine for sedation and put in soft restraints. His mental status subsequently worsens and he becomes much more aggressive, spitting at nurses and attempting to bite his restraints. He also complains of abdominal pain. A post void residual volume is notable for a urine volume of 750 mL. Which of the following is the etiology of this patient's recent mental status change?
- A. Diphenhydramine (Correct Answer)
- B. Lorazepam
- C. Haloperidol
- D. Acute infection
- E. Olanzapine
Behavioral management in dementia Explanation: ***Diphenhydramine***
- This patient exhibited a **paradoxical reaction** (increased agitation and aggression) to diphenhydramine, which is an **anticholinergic** medication.
- Anticholinergic drugs can worsen confusion and agitation, especially in elderly patients or those with pre-existing **dementia**.
*Lorazepam*
- **Benzodiazepines** like lorazepam primarily work on **GABA receptors** to produce sedative and anxiolytic effects.
- While sometimes used for agitation, it typically causes sedation rather than increased aggression in the elderly; a paradoxical reaction is less common than with anticholinergics.
*Haloperidol*
- Haloperidol is a **first-generation antipsychotic** used to treat acute agitation and psychosis, primarily by blocking **dopamine D2 receptors**.
- Its typical effect would be to decrease agitation and aggression, not worsen mental status in this manner.
*Acute infection*
- The patient initially presented with signs of an acute infection (fever, increased confusion), which improved after initial treatment with IV fluids and acetaminophen, indicating the initial symptoms were likely due to infection.
- The subsequent worsening after diphenhydramine points to a new etiology for the mental status change, rather than a resurgence of the infection.
*Olanzapine*
- Olanzapine is a **second-generation antipsychotic** that blocks serotonin and dopamine receptors, often used for acute agitation.
- Like haloperidol, it would be expected to reduce agitation and aggression, not exacerbate it, and was not administered to the patient according to the vignette.
Behavioral management in dementia US Medical PG Question 2: A 53-year-old woman presented to her PCP with one week of difficulty falling asleep, despite having good sleep hygiene. She denies changes in her mood, weight loss, and anhedonia. She has had difficulty concentrating and feels tired throughout the day. Recently, she was fired from her previous job. What medication would be most helpful for this patient?
- A. Citalopram
- B. Diphenhydramine
- C. Quetiapine
- D. Diazepam
- E. Zolpidem (Correct Answer)
Behavioral management in dementia Explanation: ***Zolpidem***
- This patient presents with **insomnia** characterized by **difficulty falling asleep**, which is the primary indication for zolpidem.
- Zolpidem is a **non-benzodiazepine GABA-A receptor agonist** that acts quickly to induce sleep, making it effective for sleep onset insomnia.
*Citalopram*
- **Citalopram** is an **SSRI** primarily used for treating depression and anxiety disorders, which are not explicitly indicated as primary issues for this patient.
- While it can sometimes help with sleep in depressed patients, its **onset of action is slow** (weeks), and it is not a first-line agent for acute insomnia.
*Diphenhydramine*
- **Diphenhydramine** is an **antihistamine** with sedative properties, often used for occasional insomnia, but it can lead to significant **daytime sedation, anticholinergic side effects**, and is generally not recommended for chronic use.
- The patient's presentation suggests a need for more targeted and potentially long-term management beyond an over-the-counter antihistamine.
*Quetiapine*
- **Quetiapine** is an **antipsychotic** medication that is sometimes used off-label for insomnia due to its sedative effects, but it carries significant **side effects** like metabolic syndrome, orthostatic hypotension, and tardive dyskinesia.
- It is generally **not recommended as a first-line treatment for insomnia** without co-occurring psychiatric conditions like bipolar disorder or schizophrenia.
*Diazepam*
- **Diazepam** is a **benzodiazepine** that can be used for insomnia, but it has a **long half-life** leading to daytime sedation and a **high potential for dependence and abuse**.
- Its use should be limited to short-term treatment of severe insomnia and is generally avoided in patients who deny mood changes and anhedonia, suggesting a less complex underlying issue.
Behavioral management in dementia US Medical PG Question 3: An investigator conducts a case-control study to evaluate the relationship between benzodiazepine use among the elderly population (older than 65 years of age) that resides in assisted-living facilities and the risk of developing Alzheimer dementia. Three hundred patients with Alzheimer dementia are recruited from assisted-living facilities throughout the New York City metropolitan area, and their rates of benzodiazepine use are compared to 300 controls. Which of the following describes a patient who would be appropriate for the study's control group?
- A. A 73-year-old woman with coronary artery disease who was recently discharged to an assisted-living facility from the hospital after a middle cerebral artery stroke
- B. An 86-year-old man with well-controlled hypertension and mild benign prostate hyperplasia who lives in an assisted-living facility (Correct Answer)
- C. A 64-year-old man with well-controlled hypertension and mild benign prostate hyperplasia who lives in an assisted-living facility
- D. An 80-year-old man with well-controlled hypertension and mild benign prostate hyperplasia who lives in an independent-living community
- E. A 68-year-old man with hypercholesterolemia, mild benign prostate hyperplasia, and poorly-controlled diabetes who is hospitalized for pneumonia
Behavioral management in dementia Explanation: ***An 86-year-old man with well-controlled hypertension and mild benign prostate hyperplasia who lives in an assisted-living facility***
- This patient meets all criteria stipulated for the control group: **older than 65 years of age**, and **resides in an assisted-living facility**.
- They also have no mention of dementia, making them suitable as a **healthy control** for the study.
*A 73-year-old woman with coronary artery disease who was recently discharged to an assisted-living facility from the hospital after a middle cerebral artery stroke*
- Although this patient is over 65 and in an assisted-living facility, a recent **middle cerebral artery stroke** could lead to **vascular cognitive impairment**, which might confound the assessment of Alzheimer's dementia.
- Controls should ideally be free of conditions that could mimic or predispose to dementia, complicating the analysis of the association with benzodiazepine use.
*A 64-year-old man with well-controlled hypertension and mild benign prostate hyperplasia who lives in an assisted-living facility*
- This patient does not meet the specified age criterion of being **older than 65 years of age**.
- All participants in the study, including controls, must be 65 years or older to maintain the integrity of the study population.
*An 80-year-old man with well-controlled hypertension and mild benign prostate hyperplasia who lives in an independent-living community*
- This patient does not reside in an **assisted-living facility**, which is a crucial inclusion criterion for all participants in this study.
- The study specifically focuses on the elderly population residing in **assisted-living facilities** to ensure a uniform study environment.
*A 68-year-old man with hypercholesterolemia, mild benign prostate hyperplasia, and poorly-controlled diabetes who is hospitalized for pneumonia*
- This patient is currently **hospitalized for pneumonia**, indicating an acute illness that would make them unsuitable for selection into a control group for a chronic disease study.
- Controls should be relatively healthy and stable; acute hospitalization suggests a compromised health state not representative of the target control population.
Behavioral management in dementia US Medical PG Question 4: Five days after undergoing surgical repair of a hip fracture, a 71-year-old man is agitated and confused. Last night, he had to be restrained multiple times after attempting to leave his room. His overnight nurse reported that at times he would be resting, but shortly afterward he would become agitated again for no clear reason. He has hypertension and COPD. He had smoked one pack of cigarettes daily for 50 years but quit 10 years ago. He drinks 1 glass of whiskey per day. His current medications include oxycodone, hydrochlorothiazide, albuterol, and ipratropium. He appears agitated. His temperature is 37°C (98.6°F), pulse is 72/min, and blood pressure is 141/84 mm Hg. Pulmonary examination shows a prolonged expiratory phase but no other abnormalities. Neurologic examination shows inattentiveness and no focal findings. He is oriented to person but not to place or time. During the examination, the patient attempts to leave the room after pulling out his intravenous line and becomes violent. He is unable to be verbally redirected and is placed on soft restraints. Laboratory studies show:
Hemoglobin 14.5 g/dL
Leukocyte count 8,000/mm3
Platelet count 245,000/mm3
Serum
Na+ 142 mEq/L
K+ 3.5 mEq/L
Cl- 101 mEq/L
HCO3- 24 mEq/L
Urea nitrogen 14 mg/dL
Creatinine 1.1 mg/dL
Urine dipstick shows no abnormalities. Which of the following is the most appropriate next step in management?
- A. Obtain CT scan of the head
- B. Obtain urine culture
- C. Administer lorazepam
- D. Administer haloperidol (Correct Answer)
- E. Obtain x-ray of the chest
Behavioral management in dementia Explanation: ***Administer haloperidol***
- The patient is exhibiting acute **delirium**, characterized by **agitation**, **confusion**, inattentiveness, and fluctuating mental status in a post-surgical setting.
- Given his **violent behavior**, inability to be verbally redirected, and **immediate danger to self/others** (pulling IV line, requiring restraints), pharmacological intervention is necessary for acute safety management.
- **Haloperidol** (a typical antipsychotic) has historically been used for severe agitation in delirium when the patient poses imminent danger, though current guidelines emphasize it should be used at the **lowest effective dose for the shortest duration** while underlying causes are addressed.
- Note: Antipsychotics do not treat the underlying delirium but manage dangerous agitation; concurrent evaluation for reversible causes (pain, infection, medications, alcohol withdrawal) remains essential.
*Obtain CT scan of the head*
- While a CT scan may be indicated in delirium workup to rule out **structural lesions** or **intracranial hemorrhage**, there are no focal neurological deficits, head trauma, or signs of increased intracranial pressure here.
- His delirium is likely multifactorial (postoperative state, opioid use, possible pain, stress), and CT would not address the immediate safety concern.
- Neuroimaging can be pursued after acute agitation is controlled.
*Obtain urine culture*
- **Urinary tract infections (UTIs)** are common delirium triggers in elderly patients, but the **urine dipstick is unremarkable** (no leukocyte esterase, nitrites, or WBCs), making UTI less likely.
- While a culture could be ordered as part of comprehensive workup, it does not address the immediate violent behavior.
*Obtain x-ray of the chest*
- A chest x-ray would be appropriate if there were signs of **pneumonia** (fever, cough, hypoxia, new lung sounds), but examination shows only a **prolonged expiratory phase** consistent with his known COPD.
- Pneumonia can cause delirium, but without acute respiratory symptoms, this is not the immediate priority over managing dangerous agitation.
*Administer lorazepam*
- **Benzodiazepines** like lorazepam are **contraindicated** in delirium unless the cause is alcohol or benzodiazepine withdrawal, as they can **worsen confusion**, cause paradoxical agitation, and increase fall risk in elderly patients.
- While the patient drinks 1 glass of whiskey daily, this level of consumption makes severe alcohol withdrawal less likely (though should still be assessed), and benzodiazepines carry significant risks of respiratory depression given his COPD.
- Antipsychotics are preferred for non-withdrawal delirium when pharmacological management is necessary.
Behavioral management in dementia US Medical PG Question 5: A 79-year-old woman who lives alone is brought to the emergency department by her neighbor because of worsening confusion over the last 2 days. Due to her level of confusion, she is unable to answer questions appropriately. She has had type 2 diabetes mellitus for 29 years for which she takes metformin. Vital signs include: blood pressure 111/72 mm Hg, temperature 38.5°C (101.3°F), and pulse 100/min. Her fingerstick blood glucose is 210 mg/dL. On physical examination, she is not oriented to time or place and mistakes the nursing assistant for her cousin. Laboratory results are shown:
Hemoglobin 13 g/dL
Leukocyte count 16,000/mm3
Segmented neutrophils 70%
Eosinophils 1%
Basophils 0.3%
Lymphocytes 25%
Monocytes 4%
Which of the following is the most likely diagnosis?
- A. Brief psychotic disorder
- B. Alzheimer's dementia
- C. Delirium (Correct Answer)
- D. Depression
- E. Delusional disorder
Behavioral management in dementia Explanation: **Delirium**
- The patient presents with **acute-onset confusion**, **disorientation** to time and place, and **misidentification of individuals**, all fluctuating symptoms characteristic of delirium.
- The presence of **fever** (38.5°C), **leukocytosis** (16,000/mm³ with neutrophilia), and **hyperglycemia** (210 mg/dL) suggests an underlying acute medical condition (e.g., infection) as a precipitating factor for delirium in a vulnerable elderly patient with diabetes.
*Brief psychotic disorder*
- This disorder is characterized by the sudden onset of **psychotic symptoms** (e.g., delusions, hallucinations, disorganized speech) lasting less than 1 month, but it is not typically associated with an acute medical illness or systemic signs like fever and leukocytosis.
- While the patient exhibits confusion, the clinical picture points more strongly to an acute organic cause rather than a primary psychiatric disorder.
*Alzheimer's dementia*
- Alzheimer's dementia typically manifests as a **gradual, progressive decline** in cognitive function over months to years, not an acute change in mental status over 2 days.
- Although advanced dementia can present with confusion and disorientation, the acute onset, fluctuating nature, and signs of an underlying infection make delirium more likely.
*Depression*
- Depression in the elderly can sometimes cause **cognitive slowing** or **"pseudodementia,"** but it does not typically present with acute disorientation, fever, or leukocytosis.
- The patient's presentation is more consistent with an acute confusional state rather than altered mood or anhedonia associated with depression.
*Delusional disorder*
- Delusional disorder involves **persistent, non-bizarre delusions** without other prominent psychotic symptoms or significant impairment in functioning, typically developing over a longer period.
- The patient's global confusion, disorientation, and acute medical signs are inconsistent with a primary delusional disorder.
Behavioral management in dementia US Medical PG Question 6: A 76-year-old man is brought to his geriatrician by his daughter, who reports that he has been "losing his memory." While the patient previously performed all household duties by himself, he has recently had several bills that were unpaid. He also called his daughter on several occasions after getting lost while driving and having "accidents" before getting to the toilet. On exam, the patient is conversant and alert to person, place, and time, though his gait is wide-based and slow. Which of the following diagnostic procedures would be most appropriate to confirm the suspected diagnosis in this patient?
- A. Warfarin
- B. Donepezil
- C. Carbidopa/Levodopa
- D. Memantine
- E. Lumbar puncture (Correct Answer)
Behavioral management in dementia Explanation: ***Lumbar puncture***
- The patient's symptoms of **cognitive decline**, **gait disturbance**, and **urinary incontinence** (losing control before reaching the toilet) represent the classic triad of **Normal Pressure Hydrocephalus (NPH)**.
- **Lumbar puncture** with removal of CSF (30-50 mL) serves as both a **diagnostic and therapeutic test** (tap test); transient improvement in symptoms, especially gait, strongly supports the diagnosis of NPH.
- This is the only **diagnostic procedure** among the options; the others are medications/treatments.
*Warfarin*
- This is an **anticoagulant medication** (not a diagnostic procedure) used to prevent blood clots in atrial fibrillation or venous thromboembolism.
- Has no role in diagnosing or treating NPH, which involves CSF dynamics, not coagulation.
*Donepezil*
- **Donepezil** is an **acetylcholinesterase inhibitor medication** (not a diagnostic procedure) used to treat Alzheimer's disease symptoms.
- While the patient has cognitive decline, the classic NPH triad (cognitive, gait, incontinence) distinguishes this from typical Alzheimer's dementia.
- This is a treatment option, not a diagnostic test.
*Carbidopa/Levodopa*
- This **medication combination** (not a diagnostic procedure) is the primary treatment for **Parkinson's disease**, replacing dopamine.
- While Parkinson's causes gait issues, it doesn't typically present with this specific triad, and parkinsonian gait differs from NPH's magnetic/apraxic gait.
- This is a treatment, not a diagnostic procedure.
*Memantine*
- **Memantine** is an **NMDA receptor antagonist medication** (not a diagnostic procedure) used in moderate to severe Alzheimer's disease.
- Like donepezil, this treats dementia symptoms but is not a diagnostic test for NPH.
Behavioral management in dementia US Medical PG Question 7: A 78-year-old man is brought to the physician by his daughter for a follow-up examination. The daughter noticed that he has gradually become more forgetful and withdrawn over the last year. He frequently misplaces his car keys and forgets the names of his neighbors, whom he has known for 30 years. He has difficulty recalling his address and telephone number. He recently had an episode of urinary and fecal incontinence. Last week, his neighbor found him wandering the parking lot of the grocery store. He has hypertension and hyperlipidemia. He had smoked one pack of cigarettes daily for 40 years but quit 18 years ago. His current medications include hydrochlorothiazide and atorvastatin. He appears healthy; BMI is 23 kg/m2. His temperature is 37.2°C (99.0°F), pulse is 86/min, respirations are 14/min, and blood pressure is 136/84 mm Hg. Mini-mental state examination score is 19/30. He is not bothered by his forgetfulness. Cranial nerves II–XII are intact. He has 5/5 strength and full sensation to light touch in all extremities. His patellar, Achilles, and biceps reflexes are 2+ bilaterally. His gait is steady. MRI scan of the brain shows ventriculomegaly and prominent cerebral sulci. Which of the following is the most appropriate pharmacotherapy?
- A. Acetazolamide
- B. Sertraline
- C. Memantine
- D. Thiamine
- E. Donepezil (Correct Answer)
Behavioral management in dementia Explanation: ***Donepezil***
- The patient exhibits features consistent with **Alzheimer's disease**, including gradual memory loss, difficulty with daily tasks, episodes of incontinence, and a Mini-Mental State Examination (MMSE) score of 19/30. Donepezil, a **cholinesterase inhibitor**, is a first-line treatment for mild to moderate Alzheimer's to slow cognitive decline.
- The MRI findings of **ventriculomegaly and prominent cerebral sulci** are consistent with general cerebral atrophy often seen in Alzheimer's disease, not hydrocephalus requiring shunting or other specific brain pathologies (normal pressure hydrocephalus would have gait disturbance as a prominent feature, which is absent here).
*Acetazolamide*
- **Acetazolamide** is a **carbonic anhydrase inhibitor** used to treat conditions like glaucoma, altitude sickness, and idiopathic intracranial hypertension.
- There is no indication of elevated intracranial pressure or hydrocephalus that would warrant the use of acetazolamide in this patient.
*Sertraline*
- **Sertraline** is a **selective serotonin reuptake inhibitor (SSRI)** primarily used to treat depression, anxiety disorders, and obsessive-compulsive disorder.
- While depression can coexist with dementia, the primary cognitive symptoms described here are not primarily depressive; therefore, an antidepressant is not the most appropriate initial pharmacotherapy for cognitive decline.
*Memantine*
- **Memantine** is an **NMDA receptor antagonist** used in moderate to severe Alzheimer's disease, often in combination with cholinesterase inhibitors or when cholinesterase inhibitors are not tolerated.
- While appropriate for moderate to severe Alzheimer's, **cholinesterase inhibitors** are typically the initial treatment for mild to moderate stages, and the patient's MMSE score of 19/30 often falls into the mild-moderate category where donepezil is usually favored first.
*Thiamine*
- **Thiamine** (vitamin B1) supplementation is primarily used to treat **Wernicke-Korsakoff syndrome**, which is associated with chronic alcohol abuse and presents with ataxia, ophthalmoplegia, and confusion, none of which are the primary presenting symptoms here.
- There is no evidence of **nutritional deficiency** or alcohol abuse in this patient to suggest thiamine deficiency as the cause of his cognitive decline.
Behavioral management in dementia US Medical PG Question 8: A 27-year-old man is brought to the emergency department from a homeless shelter because of bizarre behavior. He avoids contact with others and has complained to the supervising staff that he thinks people are reading his mind. Three days ago, he unplugged every electrical appliance on his floor of the shelter because he believed they were being used to transmit messages about him to others. The patient has schizophrenia and has been prescribed risperidone but has been unable to comply with his medications because of his unstable living situation. He is disheveled and malodorous. His thought process is disorganized and he does not make eye contact. Which of the following is the most appropriate long-term pharmacotherapy?
- A. Intravenous propranolol
- B. Intramuscular benztropine
- C. Oral haloperidol
- D. Intramuscular risperidone (Correct Answer)
- E. Oral diazepam
Behavioral management in dementia Explanation: ***Intramuscular risperidone***
- Given the patient's **non-compliance** due to an unstable living situation, a **long-acting injectable antipsychotic** like intramuscular risperidone is the most appropriate choice for long-term management. This ensures consistent medication delivery regardless of daily adherence.
- This medication directly addresses the **positive symptoms of schizophrenia** (paranoia, disorganized thought) that are evident in the patient's bizarre behavior and delusional beliefs.
*Intravenous propranolol*
- Propranolol is a **beta-blocker** used to treat anxiety, hypertension, and tremors, but it is **not an antipsychotic** and does not address the core symptoms of schizophrenia.
- It could potentially be used for symptom control like akathisia if present, but not as primary long-term pharmacotherapy for psychosis.
*Intramuscular benztropine*
- Benztropine is an **anticholinergic medication** primarily used to treat **extrapyramidal symptoms (EPS)** induced by antipsychotics (e.g., dystonia, parkinsonism).
- It does not have antipsychotic effects and would not treat the patient's psychotic symptoms.
*Oral haloperidol*
- While haloperidol is an **effective antipsychotic**, it is an **oral formulation**. Given the patient's history of **non-compliance** with oral medication (risperidone), switching to another oral antipsychotic, even one as potent as haloperidol, is unlikely to solve the adherence issue, especially in an unstable living situation.
- Long-term management requires a strategy that overcomes the compliance barrier.
*Oral diazepam*
- Diazepam is a **benzodiazepine** primarily used for anxiety, sedation, and seizure control.
- It has **no antipsychotic properties** and would not treat the underlying psychotic symptoms of schizophrenia. It would only provide temporary sedation.
Behavioral management in dementia US Medical PG Question 9: A 72-year-old woman is brought to the physician by her son for an evaluation of cognitive decline. Her son reports that she has had increased difficulty finding her way back home for the last several months, despite having lived in the same city for 40 years. He also reports that his mother has been unable to recall the names of her relatives and been increasingly forgetting important family gatherings such as her grandchildren's birthdays over the last few years. The patient has hypertension and type 2 diabetes mellitus. She does not smoke or drink alcohol. Her current medications include enalapril and metformin. Her temperature is 37°C (98.6°F), pulse is 70/min, and blood pressure is 140/80 mm Hg. She is confused and oriented only to person and place. She recalls 2 out of 3 words immediately and 1 out of 3 after 5 minutes. Her gait and muscle strength are normal. Deep tendon reflexes are 2+ bilaterally. The remainder of the examination shows no abnormalities. Further evaluation is most likely to reveal which of the following findings?
- A. Generalized cerebral atrophy (Correct Answer)
- B. Myoclonic movements
- C. Hallucinations
- D. Urinary incontinence
- E. Resting tremor
Behavioral management in dementia Explanation: ***Generalized cerebral atrophy***
- The patient's symptoms of progressive **cognitive decline**, including difficulty with navigation and memory, are classic signs of **Alzheimer's disease**.
- **Generalized cerebral atrophy**, particularly of the **hippocampus** and **temporal lobes**, is a hallmark pathological finding in Alzheimer's disease due to neuronal loss and synaptic dysfunction.
*Myoclonic movements*
- **Myoclonic movements** are sudden, brief, involuntary muscle jerks, most commonly associated with **Creutzfeldt-Jakob disease** or certain types of dementia with Lewy bodies, which are not suggested by the patient's presentation.
- While some rare forms of early-onset Alzheimer's can have atypical features, myoclonus is not a typical or early finding in the more common late-onset presentation described.
*Hallucinations*
- **Hallucinations**, particularly visual hallucinations, are frequently seen in **dementia with Lewy bodies** and **Parkinson's disease dementia**, often preceding or co-occurring with cognitive decline.
- While hallucinations can occur in late-stage Alzheimer's, they are not a prominent or early feature differentiating it from other dementias.
*Urinary incontinence*
- **Urinary incontinence** can be a symptom of various conditions, including **normal pressure hydrocephalus (NPH)**, which presents with a triad of gait instability, dementia, and urinary incontinence.
- In Alzheimer's disease, incontinence typically appears in the **later stages**, after significant cognitive impairment and functional decline have occurred.
*Resting tremor*
- A **resting tremor** is a characteristic symptom of **Parkinson's disease** and is often seen in **Parkinson's disease dementia** or **dementia with Lewy bodies**.
- The patient's neurological examination, including normal gait and muscle strength, does not suggest Parkinsonian features.
Behavioral management in dementia US Medical PG Question 10: A 77-year-old woman is brought to the physician for gradually increasing confusion and difficulty walking for the past 4 months. Her daughter is concerned because she has been forgetful and seems to be walking more slowly. She has been distracted during her weekly bridge games and her usual television shows. She has also had increasingly frequent episodes of urinary incontinence and now wears an adult diaper daily. She has hyperlipidemia and hypertension. Current medications include lisinopril and atorvastatin. Her temperature is 36.8°C (98.2°F), pulse is 84/min, respirations are 15/min, and blood pressure is 139/83 mmHg. She is confused and oriented only to person and place. She recalls 2 out of 3 words immediately and 1 out of 3 after five minutes. She has a broad-based gait and takes short steps. Sensation is intact and muscle strength is 5/5 throughout. Laboratory studies are within normal limits. Which of the following is the most likely diagnosis in this patient?
- A. Pseudodementia
- B. Normal pressure hydrocephalus (Correct Answer)
- C. Creutzfeldt-Jakob disease
- D. Frontotemporal dementia
- E. Dementia with Lewy-bodies
Behavioral management in dementia Explanation: ***Normal pressure hydrocephalus***
- The constellation of **gradually increasing confusion**, an **ataxic gait** (broad-based, short steps), and **urinary incontinence** in an elderly patient is the classic triad of **normal pressure hydrocephalus (NPH)**.
- Lumbar puncture with temporary symptom improvement or **neuroimaging** showing ventriculomegaly without significant sulcal atrophy would further support this diagnosis.
*Pseudodementia*
- **Pseudodementia** is a cognitive impairment primarily caused by **depression**, characterized by rapid onset of symptoms and often a history of mood disturbances.
- The patient's progressive decline over 4 months and lack of overt depressive symptoms make this less likely.
*Creutzfeldt-Jakob disease*
- **Creutzfeldt-Jakob disease (CJD)** is a rapidly progressive and fatal neurodegenerative disorder characterized by a very fast decline in cognitive function, typically over months, along with **myoclonus**, ataxia, and other neurological signs.
- The slower, more subtle progression of symptoms and absence of myoclonus make CJD less likely.
*Frontotemporal dementia*
- **Frontotemporal dementia (FTD)** usually presents with prominent early changes in **personality, behavior**, or **language (aphasia)**, rather than the classic NPH triad.
- While confusion can occur, gait disturbance and incontinence are not typically primary or early features.
*Dementia with Lewy-bodies*
- **Dementia with Lewy bodies (DLB)** is characterized by **fluctuating cognition**, **recurrent visual hallucinations**, and **spontaneous parkinsonism**.
- While gait disturbance can occur (parkinsonism), the absence of hallucinations and significant cognitive fluctuations makes NPH a more fitting diagnosis for the specific triad presented.
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