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Quick Recertification Series


CLINICAL ASSESSMENT * The first clinical manifestations are usually primary short-term memory loss and subtle changes in behavior. * Later signs and symptoms may include long-term memory loss, loss of speech fluency, apraxia, and loss of executive function. * Signs of depression may be seen in up to 50% of patients with later AD. * Extrapyramidal signs and psychosis may be seen much later. * Mental status testing should be performed serially for surveillance, including short-term and long-term memory, orientation, attention, verbal recall, language (written and spoken), and visual spatial. * Mini-Mental State Examination score .24 (range 0-30) * Neuropsychological testing may assist in differentiating AD from other causes of dementia. * Typically, no focal deficits are found on neurologic examination in patients with AD.

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									QRS0709.qxp     6/24/09       3:09 PM       Page 48

                           Quick Recertification Series

                                                            head injury, family history.
        Preparing to recertify (or certify for the                                                     >>QUESTIONS & ANSWERS<<
                                                          • The presence of the APOE*E4 gene
        first time) is an arduous process for
        which there is never enough time to
                                                            may indicate an increased risk.
                                                          • Early-onset AD may occur as early          1. A 74-year-old woman presents to your
        practice and test one’s knowledge. The                                                         office with a chief complaint of “forgetful-
        Quick Recertification Series is one way             as age 30 years and has a strong           ness.” Her daughter states that the
        PAs who are preparing to take the exam              familial predisposition.                   woman is becoming confused, misplacing
        can meet their informational needs. In a          • Phases of AD                               personal items, and repeating herself.
        condensed review format, the QRS                    – Limbic (2-3 years after onset):          Mental status test results show deficits in
        addresses critical topics included on the             antegrade/retrograde amnesia for         short-term memory and subtle language
        exam. It also provides practice ques-                                                          deficits. The woman has no focal neurolog-
                                                              events, loss of ability to recall past   ic finding, and her long-term memory is
        tions, answers, and their explanations.
        Successful completion of the NCCPA                    events, but will retain ability to       intact. She has had no previous treat-
        examination requires a variety of tactics.            perform many repetitive tasks of         ments for dementia. What is a good first-
        The QRS offers one more to add to your                daily living                             line treatment for this patient?
        test-taking armamentarium.                          – Parietal (3-6 years after onset): loss   a.   A cholinesterase inhibitor
                                                              of comprehension of spoken lan-          b.   An NMDA receptor antagonist
                                                              guage, apraxia of motor skills (eg,      c.   Vitamin E supplementation
                                                              bathing/dressing), inability to recog-   d.   Huperzine A
      ALZHEIMER’S DISEASE                                     nize visual and/or audio stimuli
                                                            – Late frontal (6-8 years after onset):    Answer: a
      ›GENERAL FEATURES                                       motor disturbances, primitive            Explanation: This woman is displaying
      • By definition, dementia requires a                    reflexes (grasping and sucking)          signs and symptoms of mild dementia
        loss of memory plus one other neu-                                                             and has not received any previous treat-
        rologic sign/symptom. Among these                 ›CLINICAL ASSESSMENT                         ment, making the cholinesterase inhib-
                                                                                                       itors a good first-line treatment option.
        is the loss of executive functioning,             • The first clinical manifestations are
                                                                                                       NMDA receptor antagonists are useful
        apraxia, aphasia, or agnosia.                       usually primary short-term memory          in moderate to severe Alzheimer’s dis-
      • To differentiate dementia from deliri-              loss and subtle changes in behavior.       ease (AD), and the efficacy and safety of
        um: Delirium is a problem with abili-             • Later signs and symptoms may               vitamin E and huperzine have not yet
        ty to concentrate, to focus, and to                 include long-term memory loss, loss        been established for treatment of this
        pay attention. Those with dementia                  of speech fluency, apraxia, and loss       disease.
        may have a paucity of thought but                   of executive function.
        are able to pay attention.                        • Signs of depression may be seen in         2. The presence of extrapyramidal signs
                                                                                                       in a patient with known AD suggests
      • Alzheimer’s dementia (AD) is a pro-                 up to 50% of patients with later AD.
        gressive neurologic disease that mani-            • Extrapyramidal signs and psychosis         a. The need for titration off of their
        fests with insidious decline in cogni-              m
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