A Startling Decline

A CLINICAL PROBLEM-SOLVING article by Mikael Rinne from Brigham and Women's Hospital, Boston.
An 89-year-old man was brought to the emergency room by his wife and son for an evaluation of changes in cognition and personality. Six months earlier, he began to require help managing finances and operating his computer. He had poor memory for recent events, had difficulty expressing himself, and had become increasingly irritable. He also exhibited unusual behaviors, such as eating a banana peel, pouring milk onto the table, and undressing immediately after getting dressed. He began to have difficulty walking and occasional urinary and fecal incontinence. During the course of several months, he became unable to dress, bathe, use the toilet, or walk independently.
This patient presents with progressive neurologic decline predominantly affecting his thinking and behavior. This pervasive impairment of cognitive function, including memory, language, and personality, is characteristic of dementia, defined as a progressive deterioration in cognition, behavior, or both, without impaired consciousness, that is severe enough to interfere with activities of daily living. In patients presenting with dementia, a variety of causes should be considered, including neurodegenerative, vascular, infectious, or inflammatory disease; neoplasia; toxic or metabolic disorders; hydrocephalus; and psychiatric disorders.
An interactive medical case related to this article is available at NEJM.org.
[Original Article]