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OVERVIEW
This page is dedicated to organizing various examples of standardized exam questions whose topic is Alzheimer disease (Alzheimer dementia). While this may seem a odd practice, it is useful to see multiple examples of how Alzheimer disease will be characterized on standardized exams (namely the boards and the shelf exams). This page is not meant to be used as a traditional question bank (as all of the answers will be the same), however seeing the classic “test” characterization for a topic is quite valuable.
KEY CHARACTERISTICS OF THIS CONDITION (ON EXAMS)
When it comes to standardized exams, each topic has its own “code” marked by key buzzwords, lab findings, clues, etc. If you are well versed in this code you will be able to more quickly identify the condition that is being discussed, and get the right answer on the exam you are taking. Below is the “code” for Alzheimer disease.
Chief Complaints:
- Memory loss/forgetfulness may be noticed by those around the patient (or the patient themselves). Generally short term memory loss is seen in these patients (long term memory typically intact) that is steadily progressive.
Patient History:
- Executive dysfunction: patients may no longer be able to take care of important tasks such as managing their finances, housekeeping, shopping, etc.
Clinical Workup:
- Poor short term memory recall: patients may struggle with this component of the mental status exam (recalling few items on a short term memory test).
- No focal neurological signs will be present on the physical exam.
- Atrophy of cranial structures such as diffuse cortical atrophy and/ or hippocampal atrophy may be revealed on cranial imaging.
- No other abnormalities: patients (other then then findings above listed above) will usually not have any other lab/imaging signs that can explain their symptoms.
QUESTION EXAMPLES
Question # 1
A 74 year old woman is brought to the clinic by her daughter because she has been getting increasingly forgetful over the past few years. The daughter explains that she has also had recent episodes of getting lost while walking home from the grocery store which is 2 blocks away from her house. The patient explains that her mood is “happy” and has not shown any signs of depression. The patient’s vital signs are within normal limits. She is alert and cooperative during the mental status exam, but can only recall 1 out of 5 items on a short term memory test. She undergoes an involved work up (which includes extensive lab testing, cranial imaging) which only reveals the presence of diffuse cortical atrophy (with no other abnormalities). What is the likely diagnosis in this patient?
Explanation # 1
Forgetfulness + poor score on short term memory test + cortical atrophy + no other lab/imaging abnormalities = Alzheimer disease
Question # 2
An 80 year old man comes to the physician because he has been suffering from memory loss. He lives with is son who explains that he has been having trouble remember recent discussions that they have had. The patient has also forgotten recent important events, such as the passing of his beloved dog. About 1 year ago the patient decided to stop driving because he kept getting lost on his way back from the grocery store. The patient explains that he can still remember the “good old times”, and he still enjoys going to the community rec center to play backgammon with his friends. The son expalisn that he now manages his father’s finances, and is also in charge of coordinating his health care. What condition does this patient likely suffer from?
Explanation # 2
Memory loss + issues with short term memories exclusively + executive dysfunction (son manages his finances) = Alzheimer disease
Question # 3
A 75 year old female has been suffering from steadily progressing memory loss over the last two and half years. She now needs help with daily activities such as grocery shopping, and cleaning her apartment. A cranial MRI reveals the presence of cortical and hippocampal atrophy, with no other notable findings. What is a possible diagnosis in this patient?
Explanation # 3
Progressive memory loss + executive dysfunction (help with shopping and housekeeping) + cortical/hippocampal atrophy on MRI = Alzheimer disease
Question # 4
A 78 yer old male is brought to the clinic by his daughter for routine check up. The patient believes that his daughter is a “cunning fox” and wants to steal all of his money. He accuses his daughter of trying to remove him from his home so that she can acquire all of his property. He has become progressively more forgetful over the past few years, and can not recall recent events such as the recent birth of his granddaughter. The patient does reminisce about his youth when he comments that “times were just more simple back then”. His past medical history is unremarkable, and his vital signs are within normal limits. A mental status exam reveals poor short term memory recall, and he is unsure who the current US president is. There are no focal neurological findings on his physical exam. A brain MRI reveals the presence of generalized cortical atrophy as well as a decrease in hippocampal volume. Lab tests are conducted that reveal a negative plasma reagin, a non-reactive treponema antibody absorption test, normal serum electrolytes, and thyroid function tests that are within normal limits. What is the likely diagnosis in this patient?
Explanation # 4
Progressive memory loss + issues with short term memories exclusively + poor short term memory recall on mental status exam + cortical/hippocampal atrophy on MRI + no other lab abnormalities = Alzheimer disease
Question # 5
A 65 year old male is brought to the clinic by his partner because he has been experiencing progressively worsening forgetfulness for the past few years. He has been having difficulty remember new names, and he had to retire from his job as a retail clerk because he could not remember which new products were stocked or where they were kept in the store. He also has difficulty performing some of his daily acts of living, and relies on his partner to pick his clothing outfits for him. The patient’s past medical history is unremarkable: he has no history of head trauma, does not take any medications, and denies using alcohol or illicit drugs. A physical exam is within normal limits. A Mini-Mental State Exam reveals a score of 22/30. He does not have any auditory or visual hallucinations and the results of his laboratory tests are all normal. What is the most likely diagnosis in this patient?
Explanation # 5
Progressive forgetfulness + issues with short term memory + executive dysfunction + no lab abnormalities = Alzheimer disease
Question # 6
A 75 year old male visits the clinic with his daughter because he has been having issues with his memory for the past year. He often misplaces his wallet and misses important appointments and regular family outings. While hie lives alone, he now has to rely on family members to come help with with errands and daily tasks at home. He denies smoking, drinking alcohol, or using any illicit drugs. A physical exam is performed and is within normal limits. A mental status exam reveals that he has an irritable mood, and the patient gets upset when questions are asked about his memory. He is only able to recall 2 out of 5 objects on the short term memory recall test. He has no evidence of depression, anxiety, or hallucinations. What is the likely diagnosis in this patient?
Explanation # 6
Progressive memory issues + executive dysfunction + poor performance on short term memory recall test = Alzheimer disease
Question # 7
A 60 year old woman is brought to the clinic by her son because she has recently been getting lost when driving on her way back home from the super market. The patient feels that the daughter is over-reacting. The patient had worked as an accountant for 30 years but had to retire a few years ago because the work was getting too difficult for her. Her vital signs re within normal limits. A mental status exam reveals that she is a bright affect, and she is cooperative during the exam. A Mini-Mental State Examination is 23/40. She is not able to recall any of the three words she was instructed to remember after 5 minutes. She knows her name and where she is, but does not know the date. What is the likely diagnosis in this patient?
Explanation # 7
Memory issues (getting lost when driving) + executive dysfunction (unable to work in same job) + poor performance on short term memory recall test = Alzheimer disease
TESTABLE FACTS ABOUT THIS TOPIC (BEYOND ITS IDENTIFICATION)
Many questions on standardized exams go beyond simply recognizing the underlying topic. Often there are specific testable facts regarding some aspect of the topic’s pathophysiology/management/clinical implications that are commonly asked. Some of these are listed below:
Cause:
- Decrease in acetylcholine level. Most notable in the basal nucleus of Meynert (and also hippocampus)
Histological findings:
- Amyloid-β depositions (amyloid plaques) that are extracellular
- Neurofibrillary tangles (plaques) which are intracellular hyperphosphorylated aggregates of tau protein (which essentially manifest as insoluble cytoskeletal elements). Generally, the more tangles the more advanced the degree of the dementia.
Treatment:
- Cholinesterase inhibitors such as Donepezil are often first line agents
- NMDA receptor antagonists such as memantine are also used.
Page Updated: 04.30.2017