Clinical Features

Key Points

• Dementia is characterized by multiple areas of cognitive impairment but preserved level of alertness.

• Age-related memory loss, mild cognitive impairment, depression, delirium, and DSM Axis I psychiatric disorders should be considered in the differential diagnosis of dementia.

Dementia is caused by a heterogeneous group of brain disorders that result in global impairment of cognition. In addition to memory impairment, impairment in language (aphasia), inability to carry out motor tasks (apraxia), inability to recognize objects (agnosia), and loss of executive function are seen. Mood, personality, and behavior are often affected. Dementia is distinguished from mental retardation and developmental delay by its onset after a long period of higher, often normal cognitive function. Dementia must be differentiated from delirium, as noted earlier. Of greatest utility to the primary care physician, attention is preserved in dementia, but it is altered and labile in delirium.

Some elderly persons present with a concern about mild changes in memory (inability to recall names and slower processing of information) but have no functional deficits. This age-related memory loss is thought to be normal. Of more concern is the emerging concept of mild cognitive impairment (MCI). Patients with MCI have memory concerns corroborated by an informant, objective but mild memory loss, normal general cognitive function, and intact activities of daily living (ADLs). Many, but not all, patients with MCI progress to Alzheimer-type dementia. Depression in the elderly patient can masquerade as dementia. An elderly patient might present with nondysphoric depression, marked by apathy, decreased cognitive ability, nervousness, somatization, or insomnia. This condition should be recognized and treated as depression. Patients need to be carefully followed because almost half will develop dementia within 5 years (Alexopoulos et al., 1993).

Because psychotic features can occur in delirium, dementia, and depression, psychotic mental illnesses are included in the differential diagnosis of impaired cognitive status. Key features distinguishing the causes of cognitive impairment are summarized in Table 48-1.

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