Vascular dementia US Medical PG Practice Questions and MCQs
Practice US Medical PG questions for Vascular dementia. These multiple choice questions (MCQs) cover important concepts and help you prepare for your exams.
Vascular dementia US Medical PG Question 1: A 48-year-old Caucasian man presents to your office for initial evaluation as he has recently moved to your community and has become your patient. He has no significant past medical history and has not seen a physician in over 10 years. He takes no medications and denies having any allergies. He has been a smoker for the past 20 years and smokes approximately half a pack daily. His brother and father have diabetes; his brother is treated with metformin, whereas, his father requires insulin. His father has experienced two strokes. On presentation, he is a pleasant obese man with a body mass index of 34 kg/m2. On physical examination, his blood pressure is 170/90 mm Hg in the left arm and 168/89 mm Hg in the right arm. The patient is instructed to follow a low-salt diet, quit smoking, perform daily exercise, and diet to lose weight. He returns several weeks later for a follow-up appointment. The patient reports a 1.8 kg (4 lb) weight loss. His blood pressure on presentation is 155/94 mm Hg in both arms. What is the most appropriate next step in management?
- A. Prescribe bisoprolol
- B. Reassure the patient and encourage him to continue with lifestyle modifications
- C. Prescribe hydrochlorothiazide
- D. Prescribe lisinopril and bisoprolol
- E. Prescribe lisinopril (Correct Answer)
Vascular dementia Explanation: ***Prescribe lisinopril***
- The patient has **stage 2 hypertension** (blood pressure ≥140/90 mm Hg) despite initial lifestyle modifications, necessitating pharmacological intervention.
- An **ACE inhibitor** like **lisinopril** is the most appropriate first-line agent for this patient given his **strong family history of diabetes** (both father and brother affected) and multiple cardiovascular risk factors, as it offers **renal protection** and may reduce progression to diabetes.
- ACE inhibitors are particularly beneficial in patients at high risk for diabetes and provide cardiovascular and renal protection.
*Prescribe bisoprolol*
- **Bisoprolol**, a beta-blocker, is not typically recommended as first-line monotherapy for hypertension without specific indications like **coronary artery disease**, **heart failure**, or **post-myocardial infarction**.
- Although effective for blood pressure reduction, other agents like ACE inhibitors or thiazide diuretics are generally preferred for initial management due to broader metabolic and cardiovascular benefits.
*Reassure the patient and encourage him to continue with lifestyle modifications*
- While lifestyle modifications are crucial, the patient's blood pressure remains significantly elevated at **155/94 mm Hg**, constituting **stage 2 hypertension**, which requires pharmacological treatment.
- Delaying pharmacological treatment in **stage 2 hypertension** increases the risk of **cardiovascular events** including stroke and myocardial infarction.
*Prescribe hydrochlorothiazide*
- **Hydrochlorothiazide**, a thiazide diuretic, is also an appropriate first-line agent for hypertension with proven cardiovascular benefits.
- However, in this specific patient with a **strong family history of diabetes** and multiple metabolic risk factors (obesity, BMI 34), an **ACE inhibitor** is preferred as it may offer additional benefits in **preventing progression to diabetes** and providing **renal protection**.
- Thiazide diuretics can have adverse metabolic effects including increased blood glucose and could be considered as an alternative or add-on agent if needed.
*Prescribe lisinopril and bisoprolol*
- Initiating two antihypertensive medications at once is typically reserved for patients with **stage 2 hypertension with BP ≥160/100 mm Hg** or those at very high cardiovascular risk requiring rapid BP control.
- With BP at 155/94 mm Hg, it is generally recommended to start with **monotherapy** and titrate or add a second agent if the blood pressure target is not achieved within 2-4 weeks.
Vascular dementia US Medical PG Question 2: A 66-year-old man is brought into the emergency department by his daughter for a change in behavior. Yesterday the patient seemed more confused than usual and was asking the same questions repetitively. His symptoms have not improved over the past 24 hours, thus the decision to bring him in today. Last year, the patient was almost completely independent but he then suffered a "series of falls," after which his ability to care for himself declined. After this episode he was no longer able to cook for himself or pay his bills but otherwise had been fine up until this episode. The patient has a past medical history of myocardial infarction, hypertension, depression, diabetes mellitus type II, constipation, diverticulitis, and peripheral neuropathy. His current medications include metformin, insulin, lisinopril, hydrochlorothiazide, sodium docusate, atorvastatin, metoprolol, fluoxetine, and gabapentin. On exam you note a confused man who is poorly kept. He has bruises over his legs and his gait seems unstable. He is alert to person and place, and answers some questions inappropriately. The patient's pulse is 90/minute and his blood pressure is 170/100 mmHg. Which of the following is the most likely diagnosis?
- A. Normal aging
- B. Lewy body dementia
- C. Vascular dementia (Correct Answer)
- D. Pseudodementia (depression-related cognitive impairment)
- E. Alzheimer's dementia
Vascular dementia Explanation: ***Vascular dementia***
- This diagnosis is strongly supported by the patient's **stepwise decline** in cognitive function following a "series of falls" (likely small strokes or transient ischemic attacks) and his extensive history of **vascular risk factors** including hypertension, diabetes, and previous myocardial infarction.
- The acute worsening of confusion over 24 hours, coupled with pre-existing impaired executive function (inability to cook or pay bills), is characteristic of **vascular dementia's fluctuating course** and presentation often linked to new cerebrovascular events.
*Incorrect: Normal aging*
- **Normal aging** involves a very gradual and mild decline in cognitive functions, primarily affecting processing speed and memory recall, without significant impairment in daily activities.
- This patient's rapid, stepwise decline and inability to perform instrumental activities of daily living (IADLs) such as cooking and managing finances go beyond what is considered normal cognitive changes with aging.
*Incorrect: Lewy body dementia*
- **Lewy body dementia** is characterized by prominent **fluctuations in attention and alertness**, recurrent visual hallucinations, and spontaneous parkinsonism, none of which are explicitly mentioned as primary features in this patient's presentation.
- While fluctuations in confusion are present, the history of a clear stepwise decline post-falls and significant vascular risk factors points away from Lewy body dementia as the most likely primary cause.
*Incorrect: Pseudodementia (depression-related cognitive impairment)*
- **Pseudodementia** refers to cognitive impairment that occurs in the context of **major depression**, where patients may exhibit poor concentration, memory difficulties, and psychomotor slowing that mimics dementia.
- While this patient is on fluoxetine for depression, the **stepwise decline** after clear vascular events (falls), multiple vascular risk factors, and impaired executive function point to a true neurodegenerative process rather than depression-induced cognitive changes, which typically improve with treatment of the underlying mood disorder.
*Incorrect: Alzheimer's dementia*
- **Alzheimer's dementia** typically presents with a **gradual and progressive decline** in memory, particularly episodic memory, followed by other cognitive domains over several years.
- The patient's history of a clear **stepwise decline** in function after acute events (falls) and the strong presence of **vascular risk factors** make vascular dementia a more fitting diagnosis than Alzheimer's, which is not typically associated with such a sudden, step-like progression.
Vascular dementia US Medical PG Question 3: A 63-year-old woman is brought to the clinic by her husband with complaints of cognitive decline. The patient's husband says that she has had intermittent problems with her memory for the past few years. He says she has occasional 'bad days' where her memory deteriorates to the point where she cannot perform activities of daily living. She is also sometimes found conversing in an empty room and, when inquired, she confirms that she is talking to a friend. There have also been some recent falls. There is no history of fever, recent head trauma, loss of consciousness, or illicit drug use. Past medical history is significant for bronchial asthma and osteoarthritis, both managed medically. Her mother died due to metastatic breast cancer at age 71 and her father was diagnosed with Alzheimer's disease at age 65. The patient is afebrile and her vital signs are within normal limits. Physical examination reveals a tremor present in both her hands that attenuates with voluntary movement. Deep tendon reflexes are 2+ bilaterally. Romberg's sign is negative. She has a slow gait with a mild stooped posture. Her laboratory findings are significant for the following:
Hemoglobin 12.9 g/dL
White cell count 8,520/mm³
Platelets 295,000/mm³
Serum creatinine 1.0 mg/dL
Glucose 94 mg/dL
Sodium 141 mEq/L
Potassium 3.9 mEq/L
Calcium 92 mg/dL
Ferritin 125 ng/mL
Serum B12 305 ng/L
TSH 2.1 µU/mL
Ceruloplasmin 45 mg/dL
Which of the following is the most appropriate management for this patient?
- A. Escitalopram
- B. Penicillamine
- C. Haloperidol
- D. Ropinirole
- E. Rivastigmine (Correct Answer)
Vascular dementia Explanation: ***Rivastigmine***
- The patient exhibits classic symptoms of **dementia with Lewy bodies (DLB)**, including cognitive fluctuations, visual hallucinations (conversing in an empty room), and parkinsonism (tremor, slow gait, stooped posture, and falls). **Cholinesterase inhibitors** like **rivastigmine** are the first-line treatment for cognitive and neuropsychiatric symptoms in DLB as they can help improve cognitive function and reduce hallucinations.
- While Parkinson's disease itself is not the primary diagnosis, the presence of **parkinsonian features** and cognitive decline with hallucinations makes DLB a strong consideration. Rivastigmine increases the availability of **acetylcholine** in the brain, improving cognitive function and behavioral symptoms in DLB.
*Escitalopram*
- **Escitalopram** is an **SSRI antidepressant** and would be appropriate if the patient's primary symptoms were **depression or anxiety**.
- While depression can coexist with dementia, the described symptoms of cognitive fluctuations, hallucinations, and parkinsonism are not primarily indicative of depression.
*Penicillamine*
- **Penicillamine** is a **chelating agent** used primarily in the treatment of **Wilson's disease**, which is characterized by copper accumulation.
- The patient's **ceruloplasmin levels are normal**, making Wilson's disease unlikely, and the clinical presentation does not align with typical Wilson's disease symptoms.
*Haloperidol*
- **Haloperidol** is a **first-generation antipsychotic** that could be used for severe behavioral disturbances or psychosis.
- However, in patients with **dementia with Lewy bodies (DLB)**, antipsychotics, particularly typical ones like haloperidol, can significantly worsen parkinsonian symptoms and cognitive function due to **extreme sensitivity to neuroleptics**.
*Ropinirole*
- **Ropinirole** is a **dopamine agonist** primarily used in the treatment of **Parkinson's disease** to manage motor symptoms.
- While the patient has parkinsonian features, the prominent cognitive fluctuations and visual hallucinations point more towards **Dementia with Lewy Bodies (DLB)**, where dopamine agonists can sometimes exacerbate hallucinations and other neuropsychiatric symptoms.
Vascular dementia US Medical PG Question 4: 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)
Vascular 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.
Vascular dementia US Medical PG Question 5: 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
Vascular 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.
Vascular dementia US Medical PG Question 6: A 68-year-old man seeks evaluation by a physician with complaints of worsening forgetfulness and confusion for 1 year. According to his wife, he has always been in good health and is generally very happy; however, he has started to forget important things. He recently had his driving license revoked because of multiple tickets, but he cannot recall having done anything wrong. This morning, he neglected to put on his socks and was quite agitated when she pointed this out to him. He denies having a depressed mood, sleep problems, or loss of interest. He occasionally has a glass of wine with dinner and has never smoked or used recreational drugs. His medical history and family medical history are unremarkable. His pulse is 68/min, respirations are 14/min, and blood pressure is 130/84 mm Hg. Except for a mini-mental state examination (MMSE) score of 20/30, the remainder of the physical examination is unremarkable. Imaging studies, including a chest X-ray and CT of the brain, reveal no pathologic findings. An electrocardiogram (ECG) is also normal. Laboratory testing showed the following:
Serum glucose (fasting) 76 mg/dL
Serum electrolytes:
Sodium 140 mEq/L
Potassium 4.1 mEq/L
Chloride 100 mEq/L
Serum creatinine 0.9 mg/dL
Blood urea nitrogen 11 mg/dL
Cholesterol, total: 180 mg/dL
HDL-cholesterol 45 mg/dL
LDL-cholesterol 75 mg/dL
Triglycerides 135 mg/dL
Hemoglobin (Hb%) 16 g/dL
Mean corpuscular volume (MCV) 85 fL
Reticulocyte count 0.9%
Erythrocyte count 5 million/mm³
Thyroid-stimulating hormone 3.5 µU/mL
Urinalysis
Glucose Negative
Ketones Negative
Leucocytes Negative
Nitrite Negative
RBCs Negative
Casts Negative
Which of the following is the most likely diagnosis?
- A. Alzheimer’s dementia (Correct Answer)
- B. Creutzfeldt-Jakob disease
- C. Lewy body dementia
- D. Parkinson’s disease
- E. Vascular dementia
Vascular dementia Explanation: ***Alzheimer’s dementia***
- The patient presents with **progressive memory loss** and **confusion** that has worsened over a year, along with **agitational behavior** and difficulty with daily tasks (neglecting to put on socks), which are classic symptoms of Alzheimer's dementia.
- The **MMSE score of 20/30** indicates cognitive impairment, and the absence of other neurological findings or clear vascular risk factors supports this diagnosis.
*Creutzfeldt-Jakob disease*
- This is a rare, rapidly progressive, and fatal neurodegenerative disease that typically presents with **rapidly progressive dementia**, **myoclonus**, and other neurological signs, which are not described in this case.
- The patient's symptoms have progressed over a year, which is not as rapid as the typical course of CJD.
*Lewy body dementia*
- Characterized by **fluctuating cognition**, **recurrent visual hallucinations**, and **spontaneous parkinsonism**, which are not reported in this patient.
- While agitation can occur, the core features of Lewy body dementia are absent.
*Parkinson’s disease*
- Primarily a **movement disorder** characterized by **bradykinesia**, **rigidity**, **tremor**, and **postural instability**. While dementia can occur in later stages (Parkinson's disease dementia), the initial presentation in this patient is predominantly cognitive decline without prominent motor symptoms.
- The patient's physical examination is "unremarkable," suggesting an absence of parkinsonian motor signs.
*Vascular dementia*
- Typically associated with a history of **stroke** or significant **vascular risk factors** (e.g., uncontrolled hypertension, diabetes) and often presents with a **step-wise decline** in cognitive function.
- This patient has a largely unremarkable medical history, controlled blood pressure, and normal cholesterol, and a CT scan showed no pathological findings (e.g., infarcts), making vascular dementia less likely.
Vascular dementia US Medical PG Question 7: 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
Vascular 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.
Vascular dementia US Medical PG Question 8: A 10-year-old boy is brought into your clinic by his mother for sunburns that have not been healing. The mother states that he easily gets sunburned. The mother admits she gave birth to him at home and has never taken him to see a doctor. The patient walks with a wide stance gait and appears unstable on his feet. He has an extensive erythematous, scaling, hyperkeratotic rash on his face, neck, arms and legs. After extensive workup, the patient is found to have a genetic disorder that results in defective absorption of an important vitamin. Which of the following is likely to be low if measured?
- A. Vitamin K
- B. Niacin (Correct Answer)
- C. Folate
- D. Vitamin A
- E. Vitamin B12
Vascular dementia Explanation: ***Niacin***
- The constellation of **sunburns that don't heal**, a **wide-stanced unstable gait**, and an **erythematous, scaling, hyperkeratotic rash** (consistent with dermatitis) strongly suggests **pellagra**.
- Pellagra is caused by a deficiency of **niacin (Vitamin B3)**, which is characterized by the "3 Ds": **dermatitis**, **diarrhea**, and **dementia (or neurological symptoms like ataxia)**.
*Vitamin K*
- Deficiency typically leads to **bleeding disorders** due to impaired coagulation, which is not indicated by the patient's symptoms.
- While newborns often receive a **vitamin K shot**, his current symptoms are unrelated to its deficiency.
*Folate*
- Folate deficiency primarily causes **megaloblastic anemia** and can lead to **neural tube defects** in developing fetuses.
- It does not explain the characteristic dermatological and neurological symptoms described.
*Vitamin A*
- Vitamin A deficiency is known to cause **night blindness** and **xerophthalmia** (dry eyes), and impaired immune function.
- While it plays a role in skin health, the specific rash and gait abnormalities point away from primary vitamin A deficiency.
*Vitamin B12*
- Deficiency leads to **megaloblastic anemia** with **neurological symptoms** such as peripheral neuropathy, but the dermatological manifestations (scaling, hyperkeratotic rash) and unhealing sunburn are not typical.
- The gait could be linked to neurological symptoms, but the overall presentation is better explained by niacin deficiency.
Vascular dementia US Medical PG Question 9: A 65-year-old woman comes to the physician for the evaluation of several episodes of urinary incontinence over the past several months. She reports that she was not able to get to the bathroom in time. During the past 6 months, her husband has noticed that she is starting to forget important appointments and family meetings. She has type 2 diabetes mellitus treated with metformin. The patient had smoked a pack of cigarettes daily for 45 years. Her vital signs are within normal limits. On mental status examination, she is confused and has short-term memory deficits. She walks slowly taking short, wide steps. Muscle strength is normal. Deep tendon reflexes are 2+ bilaterally. Which of the following is the most likely underlying cause of this patient's urinary incontinence?
- A. Bacterial infection of the urinary tract
- B. Normal pressure hydrocephalus (Correct Answer)
- C. Detrusor-sphincter dyssynergia
- D. Impaired detrusor contractility
- E. Loss of sphincter function
Vascular dementia Explanation: ***Normal pressure hydrocephalus***
- The patient's presentation with **urinary incontinence**, **memory deficits/dementia**, and an **ataxic gait** (slow, short, wide steps) represents the classic triad of **Normal Pressure Hydrocephalus (NPH)**.
- While the incontinence itself is urge-type (not getting to the bathroom in time), the constellation of symptoms points to NPH as the underlying neurological cause.
*Bacterial infection of the urinary tract*
- Although urinary tract infections can cause **acute urinary incontinence**, especially in the elderly, they do not explain the accompanying **memory loss** and **gait disturbance**.
- There are no symptoms typical of infection such as **dysuria**, **frequency**, or **fever** mentioned in the vignette.
*Detrusor-sphincter dyssynergia*
- This condition involves involuntary contraction of the urethral sphincter during detrusor contraction, typically seen in **spinal cord injury** patients, and is characterized by **incomplete bladder emptying**, not primarily urge incontinence alone.
- It does not account for the **cognitive decline** or **gait abnormalities** presented.
*Impaired detrusor contractility*
- **Impaired detrusor contractility** (underactive bladder) typically leads to **overflow incontinence** with incomplete emptying, characterized by a constant dribble and difficulty initiating urination, which contrasts with the presented urge incontinence.
- This condition does not explain the patient's **dementia** or **gait disturbance**.
*Loss of sphincter function*
- **Loss of sphincter function** (stress incontinence) typically causes urine leakage with increased intra-abdominal pressure (e.g., coughing, sneezing, lifting), which is different from the patient's report of not making it to the bathroom in time which points towards urge incontinence.
- This condition also does not explain the neurological symptoms of **dementia** and **gait ataxia**.
Vascular dementia US Medical PG Question 10: A 73-year-old woman is brought to the physician by her son because of increasing forgetfulness over the past 2 years. Initially, she used to misplace keys and forget her dog's name or her phone number. Now, she often forgets about what she has seen on television or read about the day before. She used to go for a walk every morning but stopped one month ago after she became lost on her way back home. Her son has prevented her from cooking because she has had episodes of leaving the gas stove on after making a meal. She becomes agitated when asked questions directly but is unconcerned when her son reports her history and says he is overprotective of her. She has hypertension, coronary artery disease, and hypercholesterolemia. Current medications include aspirin, enalapril, carvedilol, and atorvastatin. She is alert and oriented to place and person but not to time. Vital signs are within normal limits. Short- and long-term memory deficits are present. Her speech rhythm is normal but is frequently interrupted as she thinks of words to frame her sentences. She makes multiple errors while performing serial sevens. Her clock drawing is impaired and she draws 14 numbers. Which of the following is the most likely diagnosis?
- A. Lewy-body dementia
- B. Alzheimer disease (Correct Answer)
- C. Frontotemporal dementia
- D. Normal pressure hydrocephalus
- E. Creutzfeldt-Jakob disease
Vascular dementia Explanation: **Alzheimer disease**
- The patient's presentation with **progressive memory impairment** (misplacing keys, forgetting recent events), **executive dysfunction** (getting lost, leaving stove on, impaired clock drawing), and **language difficulties** (word-finding pauses) over 2 years is highly characteristic of Alzheimer disease.
- The **insidious onset** and gradual cognitive decline affecting multiple domains, along with relative preservation of motor function initially, are key diagnostic features.
*Lewy-body dementia*
- This condition is often characterized by **fluctuating cognition**, **visual hallucinations**, and **parkinsonism**, none of which are prominent in this patient's presentation.
- While memory impairment can occur, the core features of Lewy body dementia are not described here.
*Frontotemporal dementia*
- **Early behavioral changes** (e.g., disinhibition, apathy) or **prominent language deficits** (e.g., aphasia without initial memory problems) are common in frontotemporal dementia.
- This patient's primary complaint is memory loss, and behavioral changes are reactive rather than disinhibited, making frontotemporal dementia less likely.
*Normal pressure hydrocephalus*
- The classic triad for normal pressure hydrocephalus includes **gait disturbance**, **urinary incontinence**, and **dementia**.
- While dementia is present, there is no mention of gait abnormalities or urinary issues in this patient.
*Creutzfeldt-Jakob disease*
- This is a rapidly progressive and fatal neurodegenerative disorder with a typical course of **weeks to months**, not 2 years.
- It usually presents with **myoclonus**, **ataxia**, and **rapidly progressive dementia**, which are not seen in this case.
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