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Answer 1
  1. A mild form of a primary neurodegenerative cognitive disorder. Diagnosis of MCI or early dementia in highly intelligent/educated persons can be difficult and often requires a high index of suspicion and NP testing. MMSE is a useful general screening tool but has low sensitivity in this population. Obtaining collateral history is paramount, and this patient’s collateral history of decline in forming new memories and a 27/30 MMSE score (borderline abnormal for age and education) preclude normal aging. A diagnosis of MCI requires slightly abnormal cognitive function in single or multiple domains, without evidence of significant abnormalities in ADL. The diagnosis of AD requires a history of slow onset and gradually progressive decline in cognition, function, or behavior; objective evidence of deficits in memory and 1 other cognitive domain; evidence of significant functional decline that interferes with ADL, social, or occupational functions; deficits that cannot be better explained by another central nervous system or systemic illness and cannot be made in the context of encephalopathy (delirium). Major risk factors for AD include advancing age and family history; senility is not a consequence of normal aging and should raise suspicion for positive family history of dementia. VaID encompasses a heterogeneous group of syndromes; it is not defined by a specific pattern of cognitive deficits. Acute onset and step-wise decline of cognitive symptoms, history of known stroke or hypertension, and focal neurologic symptoms and signs are highly consistent with VaID but are not always present. Correlation of symptoms with brain infarction location or severe leukoaraiosis on brain imaging should be verified prior to diagnosis. Depressive symptoms, especially apathy and withdrawal, are common early manifestations of dementing processes, and a clinical depression evaluation should be included in the initial examination. Vitamin B12 deficiency and excessive alcohol intake may be responsible for this patient’s peripheral sensory polyneuropathy and may contribute to her cognitive symptoms but are unlikely to be primarily causative.

     Kawas CH. Clinical practice. Early Alzheimer’s disease. N Engl J Med 2003;349:1056-63.

    2. Mendez MF, Cummings JL. Dementia: a clinical approach. 3rd ed. Philadelphia: Butterworth-Heinemann; 2003.

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