The document outlines various case studies related to different forms of dementia and cognitive disorders, detailing patient histories, symptoms, and diagnostic possibilities. It emphasizes the importance of medical history and assessment techniques in diagnosing conditions such as Alzheimer’s disease, vascular dementia, and Lewy body dementia, along with the role of cognitive examinations like the Mini-Mental State Exam. Additionally, it discusses the management and treatment options for these conditions, highlighting the variability in dementia presentations and the potential for reversible conditions.

1. SULTANTE OF
OMAN

2. Case 1
• A 79-year-old man is admitted to the hospital
for an elective total knee replacement. He
lives by himself and performs all of his
activities of daily living. His medical history
includes degenerative joint disease, coronary
heart disease, and hypertension. He has no
history of psychiatric problems or alcohol and
drug history.

3. • In the evening, several hours after an
uneventful surgical procedure, the patient
becomes diaphoretic and tachypnic. He is
alert, but also agitated and confused, and
cannot give full attention to the hospital staff
and their questions. He does remember his
name, but does not believe that he is in a
hospital.

4. Choose the most likely diagnosis
1. Amnesic Disorder
2. Delirium
3. Dementia
4. Multi-infarct dementia

5. • For the past 10 years the memory of a 74-year-
old woman has progressively declined. Lately,
she has caused several small kitchen fires by
forgetting to turn off the stove, she cannot
remember how to cook her favorite recipes,
and she becomes disoriented and confused at
night. She identifies an increasing number of
objects as “that thing” because she cannot
recall the correct name. Her muscle strength
and balance are intact
Case 2

6. Choose the most likely diagnosis.
a.Huntington’s disease
b. Multi-infarct dementia
c. Creutzfeldt-Jakob disease
d. Alzheimer’s disease
e. Wilson’s disease

7. case 3
• A 70-year-old male with a dementing disorder
dies in a car accident. During the previous five
years, his personality had dramatically changed
and he caused much embarrassment to his family
due to his intrusive and inappropriate behavior.
Pathological examination of his brain shows
fronto-temporal atrophy, gliosis of the frontal
lobes’ white matter, characteristic intracellular
inclusions, and swollen neurons. Amyloid plaques
and neurofibrillary tangles are absent

8. Choose the correct diagnosis:
a. Alzheimer’s disease
b. Pick’s disease
c. Creutzfeldt-Jakob disease
d. B12 deficiency dementia
e. HIV dementia

9. Case 4
• 65-year-old woman with a history of MI, hypertension,
and asthma presents with new onset of hallucinations.
She can no longer sleep at night because she sees small
children and cats in her apartment. She thinks she
must be going crazy and is too frightened to explain the
symptoms to her husband. She has no prior psychiatric
history. Her vital signs are blood pressure supine
115/80 mm Hg and standing 90/60 mm Hg. Physical
examination reveals an alert, oriented elderly woman
with a slight resting tremor and mild rigidity in her
upper and lower extremities, but no cog wheeling.
Mini-mental status examination reveals deficits in long-
term recall.

10. Choose the most likely diagnosis.
a.Huntington’s disease
b. Parkinson disease
c. Creutzfeldt-Jakob disease
d. Alzheimer’s disease
e. Lewy body dementia

11. Case 5
• A 78-year-old man comes to the physician for
evaluation after falling five times in 2 months.
An x-ray skeletal survey reveals no fractures,
but the patient admits to worsening urinary
incontinence over the previous 4 months. His
wife states that his memory and concentration
have deteriorated recently.

12. Choose the most likely diagnosis.
a.Huntington’s disease
b. Multi-infarct dementia
c. Normal pressure hydrocephalus
d. Alzheimer’s disease
e. Lewy body dementia

13. A 72-year-old married man is brought for evaluation to a
primary care physician by his wife. His wife is very
concerned about her husband’s decline in memory, as
well as his development of stuttering speech and a slow
gait over the past two to three years.
She reports that he now requires assistance with bathing
and grooming, and that he has been reporting seeing
children hiding in their bedroom closet. He often
refuses to go to bed at night until he removes all of the
clothing from the closet in order to “find the children.”
He has no prior history of any medical problems and
takes no medications .
Case 6

14. On physical examination : muscle rigidity, with a
slow, shuffling gait but no tremor. The patient
appears very confused, and his score on a
Mini-Mental State Exam is 15/30
Investigations:
a complete blood count, chemistry panel, thyroid
profile, syphilis serology, and vitamin B12 and
folate levels are all within normal limits.
MRI was ordered (reveals generalized atrophy
with no sign of acute infarction) .

15. The patient’s wife calls on the day of the
scheduled MRI, stating that her husband had
become aggressive while she was trying to
dress him..
The physician prescribes risperidone 1 mg twice
per day to control his aggression. The patient
then develops profound rigidity, with difficulty
swallowing and drooling.

16. What is the most likely diagnosis?
a.Huntington’s disease
b. Multi-infarct dementia
c. Parkinson disease
d. Alzheimer’s disease
e. Lewy body dementia

17. A 78 years old female is brought to the clinic by her
daughter . The daughter tells you that her mother
is having difficulty with her memory .
2 years ago & since that time she has deteriorated in
a slow steady manner . However she is not totally
incapacitated.
She is able to perform some of the activities of daily
living : dressing & bathing .When she cooks ,she
often leaves burners on & when she drives the car
she often gets lost.

18. What are the points that make the diagnosis of
dementia most likely in this case???
The daughter states that her mother’s memory and
confusion have been getting worse
Her personality has changed ,her kind &caring mother
now displays periods of both agitation and aggression
No history of trauma
not alcoholic
PMH : unremarkable FH: unremarkable
Examinations : unremarkable

19. -Progressive deterioration of intellectual
function with preservation of consciousness .
-Most important risk factor is increasing age
5% of population over the age 65 years
20% of population over the age 80 years

21. vs.
Variable Delirium Dementia
Level of attention Impaired (fluctuated) Usually, alert
Onset acute Gradual
Course Fluctuating from hour to
hour ( sun downing)
Progressive deterioration
consciousness Clouded Intact
Hallucinations Present In advanced case
Prognosis Reversible Largely irreversible , but up
to15% due to treatable
causes and are reversible

22. • Poor memory ( more for recent)
• Impaired attention
• Aphasia, apraxia
• Disoriented
Cognition
• Odd and disorganized
• Restless, wondering
• Self neglect
Behaviour
• Anxiety
• DepressionMood

23. •Slow
•delusions
Thinking
•illusion
•hallusination
Perception
•impairedInsight

26. Alzheimer s disease 50-60%
Vascular disease 15-20%
Mixed dementia 10-20%
Other <10%
 like lewy-body dementia, pick s disease,
alcohol related,vitm B12...
aafp.org

27. Aims:
*identify rare treatable conditions that may present as dementia
*diagnose any condition that may exacerbate dementia (..eg.. Delirium, infection)
* Obtain the information needed to plan continuing care.
Assessment of functional capacity in dementia pt:
*Continence
*Dressing
*Self-care
*Cooking ability and nutrition
*Shopping/ housework
*Degree of orientation at home
*Social contact
*Safety in the home

28. • Patient history:
Interview the patient and their family members
about nature of onset, specific deficits, physical
symptoms, and comorbid conditions
Review medications, as well as family and social
history

29. • Examination:
General appearance.
Speech, mood, thinking, behavior.
aphasia, apraxia, agnosia and executive functioning.
Mini mental state examination.
Neurological examination.
Systemic examination.

30. Mini Mental State
Examination
Maximum score Score
5 ___
5 ___
3
___
5 ____
3
____
Orientation
1. What is the (year) (season) (date) (day) (month)?
2. Where are we: (state) (county) (town or city) (hospital) (floor)?
Registration
3. Name three common objects (e.g., "apple," "table," "penny"):
Take one second to say each. Then ask the patientto repeat all three after
you have said them. Give one point for each correct answer. Then repeat
them untilhe or she learns all three. Count trialsand record.
Trials: ___
Attention and calculation
4. Spell "world" backwards. The score is the number of lettersin correct order.
(D___L___R___O___W___)
Recall
5. Ask for the three objects repeated above. Give one point for each correct
answer.
(Note: recall cannot be testedif all three objectswere not remembered
during
registration.)

31. Mini Mental State
Examination- cont
Maximum score Score
2 ___
1 ___
3
___
1 ___
1 ___
1 ___
Total score:
30 ___
Language
6. Name a "pencil" and "watch."
7. Repeat the following: "No ifs, ands or buts."
8. Follow a three-stage command:
"Take a paper in your right hand, fold it in half and put it
on the floor.“
9. “CLOSE YOUR EYES”.
10. Write a sentence.
11. Copy the following design:
Scores of 24 or higher are generally
considerednormal.

32. Blood test
• FBC, ESR, CRP
• T4 and TSH
• urea and
creatinine
• glucose
• B12 and folate
• syphilis serology
• HIV
• caeruloplasmin
other
• cerebrospinal
fluid
examination
• electroencephal
ography (EEG)
Imaging
• MRI
• CT
• SPECT

33. :
Treat any treatable physical disorders
Treat the cause of superimposed delirium
Treat even minor medical problems
Involve and support relatives
Arrange help for carers
Medications for night and daytime restlessness
If home care fails, arrange hospital care

34. *Restlessness: sedative
..eg thioridazine, promazine
*Paranoid delusions: antipsychotic
*Depressive symptoms: antidepressent
*Alzheimer's disease: cholinesrerase inhibitors
..eg donepezil, rivastigmine

36. • most common type of dementia.
• The prevalence increase with age .Alzheimer’s
disease
• FH
• down syndrome
• Head injury
RF
• Accumulation B amyloidal peptide cause
progressive neural damage  increase
number of senile plaques reduced
cerebral production of acetylcholine
synthesis
Cause

37. Pathophysiology
• Genetic factors
• Pathogenesis:
Gross pathology :
o diffuse atrophy especially frontal and
temporal and parietal lobes Dilation of
ventricles

38. Con/ Pathogenesis
• Microscopic pathology:
Senile plaques, amyloid angiopathy
Neurofibrillary tangles
Biochemical pathology: 50-90% reduction in
action of choline acetyltransferase

40. • slowly progressive memory loss of
insidious onset in a fully conscious
patient
• slowly progressive behavioral changes
CF
• Aphasia
• Apraxia
• Agnosia
• Disturbance of executive functions
CF
• cholinesterase inhibitors,(donepezil,
rivastigmine, and galantamine are
currently approved
• Antiglutamatergic (memantine)
Treatment

41. • 2nd most common cause of
dementia.
VD
• Multiple infarcts of varying size
• The brain is atrophic , ventricular
dilatationPathology
• Stepwise progression
• Episodes of confusion
• Seizure
• Neurological signs
Clinical
features

42. • Vascular risk factors such as
hypertension, coronary
disease, and diabetes
mellitus
• Specific evidence of :
• strokes and transient -
ischemic attacks
• Neuroimaging evidence of
strokes
• Psychiatric disturbances (eg,
emotional lability,
depression, apathy)
Diagnostic
criteria for
Vascular
dementia:

43. • characterized by dementia and
Parkinson’s disease .
• More rapid than in Alzheimer's disease
LBD
• Lewy bodies (pale halo-like intracellular,
eosinophilic inclusions. )
Pathology
• Initially ,visual hallucination predominant .
• Fluctuating cognitive loss
• sings of parkinsonism
• Sensitive to side effects of neuroleptic
drugs
CF

44. • hydrocephalus that occurs in
adults, usually older adults.
• It is tried of: dementia, ataxia,
incontinence
Normal pressure
hydrocephalus
• The drainage of CSF is blocked
gradually, and the excess fluid
builds up slowly.cause
• Shunt surgery is the most common
treatment for the symptoms of normal
pressure hydrocephalus.
treatment

45. • A rare, progressive form of dementia
characterized by core symptoms of:
• disinhibtion, emotional lability,
apathy and or detachment
• (PICK’S DISEASE)
FTD
• front temporal atrophy in MRI or
CT.
• Cytoplasmic inclusion bodies (Picks
bodies)Diagnosis

47. • Dementia is common and its different from cognitive
decline due to normal aging process
• The most common type of dementia is AD followed by VD
• Early detection of AD plays a significant role in better
prognosis
• VD can be prevented by controlling the risk factors
• There are several treatable forms of dementia like in:
hypothyroidism, nutritional deficiencies, NPH

49. MCQ1
• One of the most common features of
neurological disorders are Language deficits
and are collectively known as
• a) Dysphasias
• b) Alogias
• c) Anomias
• d) Aphasias

50. MCQ2
• When an individual displays a deficit in the
comprehension of speech involving difficulties
in recognising spoken words and converting
thoughts into words is known as
• a) Wernicke's aphasia
• b) Broca's aphasia
• c) Beidecker's aphasia
• d) Warnick's aphasia

51. MCQ3
• If an individual has an inability to initiate
speech or respond to speech with anything
other than simple words is known as
• a) Nonfluent aphasia
• b) Fluent aphasia
• c) Disruptive aphasia
• d) Anomic aphasia

52. • Aphasia is an impairment of language.
(speak , understand ,fluency ,reading and writing)
• Most of the lesion that cause aphasia involve
dominant hemisphere. (95% of R handed people,
the L cerebral hemisphere is dominant.

54. PROCESS OF
SPEECH
TYPES OF SPEECH
DISORDERS
HEARING
UNDERSTANDING
THOUGHT &
WORD PROCESSING
VOICE PRODUCTION
ARTICULATION
DEAFNESS
APHASIA
APHASIA
DYSPHONIA
DYSARTHRIA

55. • stroke (most common cause )
• injury to the brain
• tumors in the brain
• Alzheimer's disease

56. – Broca’s anterior aphasia (expressive)
– Wernicke’s posterior aphasia (receptive)
– Conduction aphasia
– Nominal aphasia
– Global aphasia

57. Boca's Area or Brodmann areas 44 & 45
• Its The motor speech area
• posterior inferior frontal gyrus
• formation of words
• connections with the adjacent primary motor
areas
- the muscles of the larynx, mouth, tongue,
soft palate, and the respiratory muscles
• controls the output of spoken language.

58. Broca’s aphasia
• Expressive, no fluent aphasia
• comprehension is intact .
• Effortful speech and slow .
• Often associated with a right side
hemiparesis.

59. Wernicke's area or Brodmann's area 22
• sensory speech area
• superior temporal gyrus
with extensions around
the posterior end of the
lateral sulcus into the parietal region.
• It receives fibers (visual cortex and auditory
cortex in the superior temporal gyrus).
• It permits understanding written and spoken
language

60. Wernicke’s Dysphasia
• Receptive ,fluent aphasia .
• Impaired comprehension of writing or
spoken language.
• intact speech ,but not make much sense .
-Phonemic problem e.g. flush for brush

61. Conduction Aphasia
• Communication between Broca’s and
Wernicke’s area is impaired
• Repetition is impaired
• Comprehension and fluency are less affected

62. Nominal aphasia
• Naming of objects is impaired, but other
aspects of speech are intact
• Lesion is usually in the posterior dominant
temporoparietal area

64. DYSARTHRIA
• Acquired speech disorder caused by impaired
control of muscle responsible for speech
• Caused by weakness, paralysis, or
incoordnation of the speech muscle.
• The language content is normal .

65. Causes
• Stroke
• Nerve – muscle diseases eg ( Myasthenia gravis )
• Muscle disease eg ( myopathy )
• Progressive neurological disease
- Parkinson's
- Huntington's

66. Types
• Spastic ; UMN damage, bilateral
• Flaccid ; LMN damage
• Ataxic ; cerebellar damage
• Hypokinetic; extrapyramidal
- Parkinson's disease
• Hyperkinetic; extrapyramidal
- Huntington's disease
• Mixed ; multiple motor system affected

67. Spastic dysarthria
• Common type of dysarthria
• Caused by bilateral damage to UMN
• Causes
- stroke
- ALS ( amyotrophic lateral sclerosis)
- MS
• Neurological symptoms
- weakness, reduced ROM, decrease fine motor
control

68. Flaccid dysarthria
• Caused by impairment of LMNs in cranial nerve
and spinal nerve
• Weakness in speech or respiratory musculature
• Vital CNs to speech production
- trigeminal , facial , glossopharyngeal, vagus ,
accessory and hypoglossal
• Relevant SNs
- cervical and thoracic

69. Ataxic dysarthria
• Damage to cerebellum
• Primarily affect articulation and prosody
• Cuases
- Degenerative disease
- Stroke
- Toxic condition
* lead , mercury, alcoholism , cyanide
- tumors, infection

70. Hypokinetic dysarthria
• Associated with basal ganglion pathology
• The only dysarthria that may have increased speech
rate
• Causes
- Parkinson's disease
- traumatic head injury
* punch drunk encephalopathy
- toxic metal poisoning
-stroke
• Neurological symptoms
- increased muscle tone , decreased range and frequency of
movement

71. Hyperkinetic dysarthria
• Dysfunction to basal ganglia
• Produce involuntary movements that interfere
with normal speech production
• Causes
- chorea
- tardive dyskinesia
- dystonia

72. DYSPHONIA
• Is due to defect in the production of sound
CAUSES
1) Laryngeal diseases-eg;laryngitis
2) Vocal cord lesions
3) Xth cranial nerve palsy
4) psychogenic

73. Evaluation
• Assess comprehension:
– Ask the patient to carry out one, two or several steps
of command
– E.g. Stand up, jump and close the door
• Assess repetition:
– Ask the patient to repeat a sentence
• Assess naming:
– Ask the patient to name common and uncommon
things
• Assess reading and writing:
– Usually affected in dysphasia

74. Evaluation
• Dysarthria and dysphonia
– Listen to spontaneous speech, note VOLUME,
RHYTHM and CLARITY
– Ask the patient to repeat phrases like ‘yellow
lorry’ to test lingual sounds and ‘baby
hippopotamus’ to test labial sounds and some
tongue twisters
– Ask the patient to count till 30 to assess muscle
fatigue
– Ask the patient to cough and say ‘Aaah’

75. Evaluation
• Dysphasias
– During spontaneous speech, listen to FLUENCY
and APPROPRIEATNESS of content, particularly for
par aphasias and neologisms
– Ask the patient to name common objects
– Give the patient a 3-stage command
– Ask the patient to repeat simple sentences
– Ask the patient to read a paragraph
– Ask the patient to write a sentence and examine
the handwriting

76. Management
• Most patients recover spontaneously or
improve within the first month
• Speech therapy can be helpful, but unlikely to
be of benefit after the first few months

77. • Pharmacological treatment for aphasia
following stroke (Review)
• Speech and language therapy for aphasia
following stroke (Review)

78. Resources
• Macleod’s clinical examination
• Davidson’s principles and practice of medicine
• Oxford handbook of clinical medicine
• Step up to medicine