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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.
QRS0709.qxp 6/24/09 3:09 PM Page 48 Quick Recertification Series DAWN COLOMB-LIPPA, PA-C; MARGARET KING-SCHUMACHER, PA-C, MJ; AMY MERCANTINI KLINGLER, MS, PA-C 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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