Case 16
A 68-year-old man is brought to see you, his primary care physician, by family because he has taken to
wandering in the street. A couple of years ago, he started becoming “forgetful,” which he and his family
attributed to age. He would lose his train of thought, and sometimes come home from the store emptyhanded, having forgotten why he went there. He became listless and lost interest in his usual hobbies.
Recently, the decline has accelerated. He has been seen talking to empty rooms and has referred
several times to visits from his mother, who died many years ago. His general examination is normal.
On neurological examination, his MMSE score is 19, with points lost on orientation, recall, and intersecting pentagons. Cranial nerves and reflexes are normal.

1) Summarize the case briefly, including neuroanatomic localization and pathogenesis.
2) What is the most likely diagnosis? Name 1-2 alternative diagnoses, and discuss briefly why these are less likely.
3) What additional information (history, exam, laboratory or other studies) would you like to obtain?
What laboratory findings would you expect if your most likely diagnosis is correct?
4) Assuming your most likely diagnosis is correct, how would you manage this patient? Include doses
for one medication you might prescribe, along with an estimate of the cost of a month of your proposed therapy. How would you counsel the patient about his condition and about any proposed therapy?

A 68-year-old man becomes forgetful

A 68-year-old man is brought to see you, his primary care physician, by family because he has taken to wandering in the street. A couple of years ago, he started becoming “forgetful,” which he and his family attributed to age. He would lose his train of thought, and sometimes come home from the store emptyhanded, having forgotten why he went there. He became listless and lost interest in his usual hobbies.
Recently, the decline has accelerated. He has been seen talking to empty rooms and has referred several times to visits from his mother, who died many years ago. His general examination is normal.
On neurological examination, his MMSE score is 19, with points lost on orientation, recall, and intersecting pentagons. Cranial nerves and reflexes are normal.

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