COGNITIVE DECLINE

DEFINITION
Mild cognitive impairment: memory impairment not yet impacting on fxal ability
Delirium: acute change in cognition & confusional state, usually organic in cause, fluctuating course
Dementia: chronic & progressive, decline in cognitive ability in more than one of memory, etc with lost of fxal
ability

KEY CLINICAL FEATURES

Nature of memory prob Timeline, examples of incidents
Level of fx
Contributing factors level of education, drinking, trauma
Associated symptoms depression
Meds hx
Psychiatrics, neurological symptoms

5 DEMENTIA SYNDROME
Alzheimer
Vascular
FTD
Lewy Body
Assocd with Parkinsons

DDX
Delirium tx underlying cause
B12 defy Wernicke (REVERSIBLE)
Thyroid dzs (REVERSIBLE)
Meds-related
SOL brain tumours
Pseudo-dementia (depressive disorders) ask about mood
Hypoglycaemia
Infections encephalitis (usually acute) - HSV
Alcohol-induced
Post-hypoxia syndrome
N P hydrocephalus

INVESTIGATIONS
MMSE (Mini-Mental State Examination)
o best, quick screening tool
o >26: N, 20-25: mild, 10-20: mod, <10: severe
MOCA (Montreal Cognitive Assessment) by OT
CAMCOG (Cambridge Cognition)
FAB (Frontal Assessment Battery)
ACE-R (Addenbrookes Cognitive Score) by OT
*flaws: cognitive decline may be masked among higher-educationed pts

Blood
B12, thyroid (reversible), folate (in alcoholics)
full blood screen: glucose, toxicology, FBC (WCC, anaemia), Fe studies (haemochromatosis), Ca + bone profile (hx
of prev malignancies myeloma), screen for neurosyphilis (if hx suggests)
U&E

Imaging
CT brain (1st), MRI outrile SOL, hydroceph, chronic vasc injury, atrophy even if N, do NOT rule out dementia
(HX IMPORTANT!), PET & SPECT (not routinely done in practice)

Others
In young: EEG, LP
brain biopsy rule out vasculitis
CASES
1. A 75 year old man presents to the Geriatric Medicine outpatient clinic as a referral from his general
practitioner. He has a two year history of gradual onset short term memory loss, forgetting names, losing
his keys etc. He has stopped engaging in his usual weekly card game with friends and his wife has taken over
managing the finances at home.

DDX
Alzheimers dementia
o Amnesia (semantic memory & immediate recall) happen first, episodic
o aphasia, agnosia, speech difficulty, visuospatial probs, behavioural disturbance + psychological (later on)

2. A 75 year old man presents to the Geriatric Medicine outpatient clinic as a referral from his general
practitioner. He also attends the diabetic clinic. He has a two year history of memory loss, which seemed to
come on quite quickly initially. He deteriorated significantly after a urinary tract infection last year and
again after an admission to hospital for a TIA. He has also had a number of falls over the last year.

DDX
Vascular
o Step-wise deterioration, assocd cdiac RF (high BP, smokes, PVD), personal fam hx, focal neurological
symptoms, risk assessment (falls-prominent gait issues), urinary incontinence early on , contributing factor
(UTI in this case)
o Memory later on (x as prominent as Alzheimer)
o Exam: Afib, carotid bruits, focal neurological signs

3. A 75 year old man presents to the Geriatric Medicine outpatient clinic as a referral from his general
practitioner. He has a two year history of some mild memory impairment which seems to fluctuate over the
course of the day. In addition, he often becomes abruptly drowsy for short periods of time a few times a day.
He reports sometimes seeing people in the room who arent real. He also feels that his mobility has
deteriorated and reports being stiff.

DDX
Lewi Body Dementia
a)Cognitive fluctuations
o Fluctuating attention: episodes of drowsiness, staring into space & obtunded (absence-type episodes), long
naps during day, disorganized speech
b)Visual hallucinations
o colors, shapes, animals, people auditory/tactile/touch with good insights that they are not real
c) Autonomic
o Parkinsonisms (TRAP) if given anti-psychotics, parkinsonism will worsen, tremor not as prominent as in
Parkinson
o Sleep difficulties
o Depression: co-morbid
o Poor regulations of body function: Low BP, pulse, sweating and digestive
MRI can see Lewy body :focal atrophy of the brain
Histology lewy body (eosinophilic intracytoplasmic nuclear inclusions due to aalph-synuclein conformation)

MX
Biological tailored to MMSE (level of severity), do not alter dzs course
ACHerase inhibitors- CId in pts with heart blocks, hx of ulcer dzs
NMDA antags
Anti-depressants- start at low dose, at later stage
RF
Vascular
Social
MDT social worker, carer supports, need for residential care, OT, physiotherapies
 9.COUGH
CASES
1. A 30 year old man presents with shortness of breath, cough, and wheezing that worsen in cold air. He has
had several such episodes in the past 4 months.
DDX
Chronic asthma: triggered symptoms (smoking, exercise, weather), atopy
COPD (Chronic bronchitis): if cough productive, A1AT defy. Less likely for this age & non-smoker
PF: if cough dry
GORD: chronic cough, could trigger & worsen asthma
Pneumonia: if acute
Meds: ACEi vagus nerve irritation, failure to inhibit bradykinin (increased)
Allergic rhinitis
TB: not cause no haemoptypsis, on exposure, night sweats do CXR (consolidation/ air cavitations at apices) +
Mantoux test (not reliable if ve, cud mean recently vaccinated, -ve useful), culture (6weeks to culture TB), Z&N
stain (quicker), isolate if actively produce sputum
*RLN palsy (any age, risk from recent surgery, hoarseness & stridor)

MX
Bronchodilator: B agonists (SABA PRN, LABA regularly)
ICS
Leukotriene antag: montelukast

2. A 56 year old woman presents with shortness of breath and productive cough that lasts for at least 3
months each year in the past 2 years. She is a heavy smoker.
DDX
COPD (chronic bronchitis)
New onset asthma: age < likely
Bronchiectasis
ILD: IPF- occupation: coal mines, silica, exposure to asbestos fr buildings, farmer (pigeons fancier, hays),
chronicity, meds, PMH RA, inhalational heroin
Recurrent aspiration pneumonia in right lung base: Right main bronchus (> straight path). Why aspirate?
Intubated (in ICU or on tracheostomy), achalasia, oesophageal stricture, stroke pts whos on thickened diets
HF: not because no orthopnea & PND

3. A 58 year old man presents with 1 week of pleuritic chest pain, fever, chills, and cough with purulent yellow
sputum. He is a heavy smoker with COPD.
DDX
Bacterial pneumonia: Bacterial (purulent sputum), on PE: dullness to percussion , increase to vocal resonance,
coarse early inspiratory crepitations (infections) VS fibrosis (fine volcro-ey creps) VS fine in pulm oedema
Asthma
TB

INVESTIGATIONS
FBC: WCC high (if low: if already severe sepsis), cell differential (neutrophils high if bacterial, lymphocytosis if
viral), pL high (acute phase response- infection, bleeding, sepsis), Hg (low-anaemia, could be high-polycythaemia
in chronic dzs)
CRP
Blood cultures
CXR: consolidation

TX
Ab: CAP (co-amoxiclav + clarithromycin, flucloxacilin or cephalosposrin (could also be allergic to ceph) if
penicillin allergic
4. A 55 year old man presents with increased dyspnoea and sputum production for the past 3 days. He has
COPD and stopped using his inhalers last week. He stopped smoking 2 days ago.
DDX
Acute exacerbation of COPD
o non-infective: identifiable triger
o infective: sputum production
Asthma
Bronchiectasis
Foreign body aspiration

INVESTIGATIONS
Peak flow meter

5. A 34 year old female nurse presents with worsening cough of 6 weeks duration accompanied by weight
loss, fatigue, night sweats, and fever. She has a history of contact with tuberculosis patients at work.
DDX
Pulmonary TB: worsening cough + systemic (wt loss + fatigue +night sweats + fever) + hx of contact with TB pts
Hodgkins lymphoma: B symptoms fever, night sweats, wt loss + age. Esp if has lymphadenopathy, young
Pulmonary carcinoma: wt loss, chronic
Exacerbation of COPD: < likely for age & non-smoker
Atypical pneumonia: if acute, esp if productive purulent cough?. Legionella & mycoplasma, if HIV
(seroconversion syndrome systemic symptoms)
Sarcoidosis: dry cough
ILD

MX
RIPE meds for 8 weeks, follow up for 16weeks while waiting for C&S results
LFTs (rifampicin cause LFT derangement), eyes (colour vision, Ischihara test optic neuritis caused by
ethambutol)
work: stopped fr sputum production until resolved

6. A 50 year old male presents with a cough that is exacerbated by lying down at night and improved by
propping up on 3 pillows. He also reports exertional dyspnoea.
DDX
HF: PND, orthopnea, adding pillows
+ask: cardiac RFs (HTN, angina ,smoking, high chol, alcohol-dilated cdiomyopathy, fam hx0