Neurocognitive Disorders

Match each clinical presentation to the most likely underlying neurocognitive etiology.

A 72-year-old man is brought to the clinic by his wife due to a 1-year history of progressive memory decline. She reports that his cognitive abilities fluctuate significantly; on some days he is highly alert, while on other days he is deeply confused. Over the past 6 months, he has frequently reported seeing small animals in their living room, even though none are present. Additionally, his sleep is highly disturbed; he often yells and physically thrashes in bed, appearing to act out his dreams. On physical examination, the patient has a shuffling gait, a resting tremor in his right hand, and mild cogwheel rigidity. Laboratory studies reveal a thyroid-stimulating hormone (TSH) level of 2.1 µU/mL (normal: 0.4-4.0 µU/mL) and a normal vitamin B12 level. Which of the following is the most likely diagnosis?

A 68-year-old retired female executive presents to an outpatient memory clinic, expressing profound distress that she is developing early-onset Alzheimer disease. She reports a 3-month history of significant cognitive decline, stating, "My brain is just broken; I can't remember anything anymore." During the Montreal Cognitive Assessment (MoCA), she makes poor eye contact and frequently answers "I don't know" to orientation and recall questions; however, when gently encouraged by the physician to guess, she answers the majority of the questions correctly. She also reports early morning awakenings, a 4.5-kg (10-lb) weight loss, and a feeling that her life lacks purpose since her retirement 4 months ago. She currently takes no medications. A recent laboratory workup shows a normal thyroid-stimulating hormone (TSH) level and a normal free T4 level. Which of the following is the most appropriate initial management step for this patient?

Correlate the following classic clinical symptom constellations with their most appropriate neurocognitive disorder diagnosis.

A primary care physician is evaluating a 74-year-old patient who presents with her son for a routine wellness visit. The son mentions that his mother has been repeatedly asking the same questions and occasionally getting lost in familiar neighborhoods over the past year. Arrange the following steps in the most appropriate chronological order for the standard clinical evaluation and management of this patient's suspected cognitive impairment.

A 72-year-old woman is brought to the clinic by her daughter due to a 1-year history of progressive memory loss, misplacing items, and getting lost in familiar neighborhoods. Arrange the following steps in the most appropriate chronological order for the initial diagnostic evaluation of this patient's progressive cognitive decline.

A 54-year-old man is brought to the outpatient psychiatry clinic by his wife due to a 4-month history of significant behavioral changes. Previously known as a quiet and highly professional bank manager, he has recently become excessively blunt, apathetic, and socially disinhibited. Last week, he made explicit sexual remarks to a neighbor and was reprimanded at work for taking food directly off a colleague's desk. He has no prior psychiatric history. His medical history includes hypertension and hyperlipidemia. He currently takes lisinopril and atorvastatin; he also recently started occasionally taking his wife's fluoxetine. Vital signs are within normal limits. Laboratory results, including a complete blood count, comprehensive metabolic panel, and a normal thyroid-stimulating hormone (TSH) level, are unremarkable. On mental status examination, he is alert and fully oriented. His short-term memory recall is intact, but he demonstrates significant impairments on the trail-making test and verbal fluency tasks. Which of the following is the most likely diagnosis?

A 69-year-old man is evaluated in the hospital after being admitted for urosepsis. Over the past 24 hours, he has become profoundly confused and agitated, attempting to strike the nursing staff and pull out his intravenous lines. His medical history is significant for an 11-month history of progressive cognitive decline. His wife reports that over the past year, he has had episodes of staring blankly for prolonged periods, recurrently claims to see small animals running across the living room floor, and frequently kicks and thrashes while asleep. Physical examination earlier in the admission revealed increased resistance to passive movement in all four extremities and a slow, shuffling gait. The primary team decides that pharmacological intervention is urgently necessary to prevent the patient from harming himself and staff. Administration of which of the following medications is most likely to provoke a severe, potentially fatal deterioration characterized by extreme rigidity and autonomic dysfunction in this patient?

An 81-year-old man is brought to the primary care clinic by his son due to a 9-month history of gradual memory decline. The son reports that the patient frequently repeats questions, has stopped managing his own finances, and recently got lost while walking in his familiar neighborhood. The patient has a history of hypertension and osteoarthritis. Vital signs are within normal limits, and the physical examination is unremarkable. After completing a thorough clinical history and medication review, arrange the following steps in the diagnostic evaluation of this patient's suspected neurocognitive disorder in the most appropriate chronological order, from the immediate next step to advanced workup.

An accompanied 71-year-old male patient presents to the geriatrics clinic for the evaluation of distressing 'visions' that have worsened over the past 11 months. According to his daughter, who lives with him, the patient frequently sees unfamiliar people sitting in their living room. These detailed visual hallucinations cause him severe agitation. Over the same timeframe, his cognitive abilities have declined, characterized by pronounced day-to-day fluctuations in attention and alertness. The daughter also reports that he often shouts and thrashes during sleep. Physical examination reveals an expressionless face, right-sided resting tremor, and cogwheel rigidity in the upper extremities. Initial non-pharmacological management, including environmental modifications, has failed to alleviate his distress. Which of the following is the most appropriate initial pharmacological therapy for this patient's visual hallucinations?

An 82-year-old female is currently hospitalized on the medical ward for treatment of community-acquired pneumonia. On hospital day 3, the nursing staff urgently reports that the patient has become acutely agitated, is forcefully pulling at her intravenous lines, and claims she sees insects crawling on the ceiling. According to her family, she lives independently and her baseline cognitive status is fully intact. Arrange the following steps in the evaluation and management of this patient's acute change in mental status in the most appropriate chronological sequence, from the initial, most immediate action to the intervention of last resort.

Match each patient's core clinical presentation and disease progression pattern to the most likely neurocognitive disorder diagnosis.

A 71-year-old retired architect is brought to the neurologist by his daughter due to a 9-month history of progressive cognitive decline. Initially, he began having difficulty organizing his finances and interpreting architectural blueprints. Six months ago, he started experiencing vivid episodes during sleep where he thrashes around and shouts, sometimes injuring his wife. Over the last 3 months, he has reported seeing silent, unfamiliar children playing in his living room, though he is generally not distressed by them. He has a history of major depressive disorder treated with sertraline. Two weeks ago, his primary care physician suspected an underlying bipolar diathesis but ultimately only increased his sertraline dose. A few days later, he was prescribed linezolid at an urgent care clinic for a suspected skin infection. A thyroid panel obtained last week showed a TSH of 0.1 μU/mL (normal: 0.4-4.0 μU/mL) and a free T4 of 0.6 ng/dL (normal: 0.9-1.7 ng/dL). On physical examination today, his temperature is 37.1°C (98.8°F), blood pressure is 128/82 mmHg, and heart rate is 76/min. He has a mask-like facies and increased resting muscle tone with a catch-and-release pattern in both arms. Deep tendon reflexes are 2+ bilaterally without clonus. His Mini-Mental State Examination score is 21/30. Which of the following is the most likely diagnosis?

A 78-year-old man with an 8-year history of Parkinson disease is brought to the geriatrics clinic by his daughter. Over the past 6 months, he has exhibited progressive memory loss, difficulty paying bills, and fluctuating attention. During the last 2 weeks, he has developed vivid, terrifying visual hallucinations of strangers in his bedroom, leading to severe agitation. His vital signs and physical examination are unchanged from his baseline. His current medications include carbidopa-levodopa, pramipexole, trihexyphenidyl, and omeprazole. The physician determines that a stepwise approach is required to manage his neuropsychiatric symptoms while attempting to preserve motor function.

Arrange the following management steps in the most appropriate sequential order, from the initial most necessary action to the final therapy of last resort.

A 68-year-old man is brought to the geriatric psychiatry clinic by his son for evaluation of worsening memory. The son reports that his father has been increasingly forgetful over the past 4 months, frequently missing appointments and neglecting to pay bills. The patient's wife passed away unexpectedly 6 months ago. Since her death, the patient has lost 5 kg (11 lbs), complains of waking up at 3:00 AM every morning and being unable to return to sleep, and has lost interest in his usual hobby of gardening. During the interview, the patient makes poor eye contact and appears apathetic. When asked about recent news events to test his memory, he immediately sighs and responds, "I just don't know, my memory is terrible." With significant encouragement and prompting, he is able to recall 2 out of 3 words after 5 minutes and correctly draw a clock. His physical and neurological examinations are unremarkable. Which of the following clinical features most strongly supports a diagnosis of major depressive disorder with cognitive impairment (pseudodementia) rather than Alzheimer disease in this patient?

A 79-year-old woman is brought to the emergency department from a memory care facility due to a 3-day history of extreme agitation and visual hallucinations. Staff report she has been picking at the air and describing "spiders on the ceiling." The patient has a 4-year history of Major Neurocognitive Disorder due to Alzheimer disease, with a baseline Mini-Mental State Examination score of $17/30$. Five days ago, she was evaluated for new-onset urinary incontinence, and a new medication was prescribed.

Her current daily medications include donepezil and sertraline. Her son, who is visiting from out of state and is not her legally appointed healthcare proxy (her daughter holds this role), is highly distressed and demands the physician immediately administer heavy sedatives to "calm her down."

On examination, the patient's temperature is $37.8^\circ\text{C}$ ($100.0^\circ\text{F}$), pulse is $110/\text{min}$, and blood pressure is $142/86 \text{ mm Hg}$. She is disoriented, continuously muttering, and unable to participate in cognitive testing. Pupils are $6 \text{ mm}$ bilaterally and minimally reactive to light. Mucous membranes are extremely dry. Abdominal examination reveals absent bowel sounds and a palpable, dull suprapubic mass.

Laboratory results show:
Thyroid-stimulating hormone (TSH): $0.2 \text{ \mu U/mL}$ (Normal: $0.5 - 5.0 \text{ \mu U/mL}$)
Free T4: $1.3 \text{ ng/dL}$ (Normal: $0.9 - 1.7 \text{ ng/dL}$)
Urinalysis: Negative for leukocyte esterase and nitrites.

Which of the following is the most appropriate next step in management?

A 74-year-old retired teacher presents to the geriatrics clinic accompanied by her husband. Over the past 6 months, she has become increasingly unsteady on her feet, with her husband describing her walking as if her feet are 'glued to the floor.' Recently, she has also experienced several episodes of urinary incontinence and seems more forgetful than usual. Physical examination reveals a magnetic, broad-based gait with preserved arm swing. There are no focal motor or sensory deficits. To properly evaluate and manage this patient's most likely condition, arrange the following clinical steps in the most appropriate sequential order.

A 64-year-old man is brought to the clinic by his husband for a 9-month history of progressive memory impairment, worsening apathy, and newly developed difficulty managing their household finances. His husband notes that the patient experienced a severe major depressive episode following an early retirement a year ago, which was partially responsive to a selective serotonin reuptake inhibitor. Physical and neurologic examinations reveal no focal deficits. The physician suspects a neurocognitive disorder but must carefully differentiate this from other etiologies, particularly given the prominent psychiatric history.

Arrange the following diagnostic steps in the most appropriate sequential clinical order, proceeding from the initial baseline evaluation to the most advanced, specialized investigations.

An 82-year-old man arrives at the emergency department accompanied by his daughter due to severe agitation, disorientation, and visual hallucinations that began acutely $48$ hours ago. He repeatedly points to the corner of the room, claiming that intruders are hiding there. His daughter notes that over the past $3$ years, he has developed mild forgetfulness, such as occasionally misplacing his keys, but he has always remained independent in his daily activities. His medical history includes hypertension, osteoarthritis, and major depressive disorder. His daily medications include lisinopril and fluoxetine. Two weeks ago, he was prescribed tramadol for worsening knee pain. Vital signs show a temperature of $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure of $130/80\text{ mmHg}$, and a heart rate of $82\text{/min}$. Physical examination reveals no focal neurologic deficits, normal muscle tone, and absent clonus. He is unable to recite the months of the year backward. Laboratory testing reveals a thyroid-stimulating hormone (TSH) level of $2.1\text{ }\mu\text{U/mL}$ (normal: $0.5-5.0\text{ }\mu\text{U/mL}$) and free thyroxine (T4) of $1.2\text{ ng/dL}$ (normal: $0.9-2.4\text{ ng/dL}$). Urinalysis is positive for leukocyte esterase, nitrites, and numerous leukocytes. What is the most accurate diagnosis for this patient's current presentation?

An $80$-year-old man with a history of moderate Alzheimer disease and benign prostatic hyperplasia is brought to the emergency department by his daughter, who is his legally appointed healthcare proxy. Over the past $48$ hours, he has become acutely agitated, disoriented, and has been grasping at invisible objects. Two days ago, he started taking an over-the-counter diphenhydramine preparation for insomnia. The patient's visiting son arrived today and insists the patient be transferred immediately to a psychiatric facility. A recent outpatient urine culture grew $>10^5 \text{ CFU/mL}$ of Escherichia coli sensitive to nitrofurantoin and cephalexin. Recent thyroid tests showed a serum thyroid-stimulating hormone of $1.5 \ \mu\text{U/mL}$ (normal: $0.4-4.0 \ \mu\text{U/mL}$) and a free thyroxine of $0.5 \text{ ng/dL}$ (normal: $0.9-2.4 \text{ ng/dL}$). Vital signs show a temperature of $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure $135/85 \text{ mm Hg}$, pulse $108\text{/min}$, and respirations $16\text{/min}$. Physical examination reveals dry oral mucosa, flushed skin, and a palpably distended bladder. Which of the following is the most appropriate initial management for this patient?