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In the Clinic |

Dementia

Peter V. Rabins, MD, MPH; and David M. Blass, MD
Ann Intern Med. 2014;161(3):ITC1. doi:10.7326/0003-4819-161-3-201408050-01002
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This issue provides a clinical overview of dementia, focusing on prevention, diagnosis, treatment, practice improvement, and patient information. The content of In the Clinic is drawn from the clinical information and education resources of the American College of Physicians (ACP), including ACP Smart Medicine and MKSAP (Medical Knowledge and Self-Assessment Program). Annals of Internal Medicine editors develop In the Clinic from these primary sources in collaboration with the ACP's Medical Education and Publishing divisions and with the assistance of science writers and physician writers. Editorial consultants from ACP Smart Medicine and MKSAP provide expert review of the content. Readers who are interested in these primary resources for more detail can consult http://smartmedicine.acponline.org, https://mksap.acponline.org/, and other resources referenced in each issue of In the Clinic.

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Poorly worded questions # 2 and 4 in test
Posted on August 9, 2014
Richard Schreiber, MD, FACP
Holy Spirit Hospital, Camp Hill, PA
Conflict of Interest: None Declared
Question 2 in the test for dementia explores underlying causes for delirium superimposed on dementia in an elderly, acutely ill woman. Although it is certainly true that the patient's 3 anticholinergic/sedative meds are a) potentially inappropriate in an elderly woman to begin with, and b) are certainly complicating her acutely illness, it is not appropriate to simply "discontinue" these medications abruptly. Acute withdrawal from the amitriptyline, and especially the alprazolam, could heighten her delirium, complicate her illness, prolong her hospitalization, risk institution of even more toxic antipsychotic medications, and could contribute to falls and other trauma. A better answer would be "taper, with the intent of discontinuing, the anticholinergic and sedating medications."

Question 4 specifically asks the clinician to distinguish the best treatment for a patient with early cognitive decline and functional disability. The text specifically indicates (page ITC 7) that patients with MCI have "cognitive decline without impaired function." To me, this patient has impaired function manifested by losing her keys and inability to remember the course of her day, a constricted social sphere, and an altered affect (lowered self esteem), all likely pointing to possible Alzheimer's or frontotemporal dementia. If the former, an anti cholinesterase inhibitor may help to slow the progression of disease. In any event, MCI is a less likely diagnosis.
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