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Neurological Disorders of Stance and Gait 263 Neurological Disorders of Stance and Gait Supratentorial lesions White matter disease – White matter dis- Normal histology generic vardenafil 20mg without a prescription how does an erectile dysfunction pump work, but vascular or ischemic disease has ease in the elderly been present in cases with pronounced changes on MRI or CT – Leuko- Familial disorder of white matter disease may manifest encephalopathies itself as impaired gait; e buy 20 mg vardenafil mastercard impotence bike riding. The lesions are clustered in the superior portion of the ventrolateral nucleus of the thalamus and the suprathalamic white matter – Capsular and basal Small capsular lesions involving the most lateral por- ganglia lesions tion of the ventrolateral nucleus of the thalamus, and multiple bilateral lacunae in the basal ganglia, can be attended by gait impairment Normotensive hydro- Significant dilatation of the lateral, third, and fourth cephalus ventricles and blunting of the callosocaudal angle causing spastic gait ataxia and urinary disturbances. Fibers destined for the leg region course in the poste- rior limb of the internal capsule and then ascend in the more medial portion of the corona radiata, near the wall of the lateral ventricle Bilateral subdural Unilateral chronic subdural hematomas cause a mild hematomas hemiparesis, speech and language disorders, and apraxia. Bilateral lesions present with gait failure, par- ticularly in elderly individuals Infratentorial lesions Pontomesencephalic The pedunculopontine region plays an important role gait failure in motor behavior. Loss of neurons in the area causes an acute onset of inability to walk, without hemipare- sis or sensory loss and lack of cadence or gait rhyth- micity. The gait deficit resembles the gait failure ex- perienced by many elderly individuals without a clear anatomical correlate Tsementzis, Differential Diagnosis in Neurology and Neurosurgery © 2000 Thieme All rights reserved. Most often, patients with cerebellar lesions tend to fall to the side of the lesion Myelopathy The initial manifestation of a myelopathy is often gait or balance impairment Cervical spondylosis Advanced disease may lead to tetraparesis with a spastic–ataxic gait, and may be associated with radic- ular findings, such as pain and reflex changes Multiple sclerosis Gait or balance impairment and sensory changes may be the only manifestations of MS involving the spinal cord or, rarely, some of the higher levels of neuraxis AIDS:acquiredimmunedeficiencysyndrome;CT:computedtomography;MRI:magneticres- onance imaging; MS: multiple sclerosis. Types of Stance and Gait Watching the patient stand and walk is the single most important part of the entire neurological assessment and examination. Developmental gaits Neonatal automatic or When the infant is held upright and its feet touch the reflex stepping bed surface, it reflexly lifts its legs alternately and steps Infantile cruising The infant makes steps when steadied by a parent, or when holding on to a chair Toddler’s gait Broad-based, short, jerky, irregular steps, a semiflexed posture of the arms, and frequent falls Child’s mature gait Narrow-based, heel–toe stride, reciprocal swinging of the arms Neuromuscular gaits Clubfoot gait The gait depends on which of a variety of valgus– varus deformities exists In-toed or pigeon-toed When there is tibial torsion gait Tsementzis, Differential Diagnosis in Neurology and Neurosurgery © 2000 Thieme All rights reserved. Types of Stance and Gait 265 Lordotic waddling gait In muscular dystrophy and polymyositis, these patients find it difficult to get up onto, or down from, the examining table, or difficult to stand up from a sit- ting or reclining position Toe-drop or foot-drop Because of paralysis of foot dorsiflexion, patients are gait unable to clear the floor, and consequently jerk the knee high, flipping the foot up into dorsiflexion, and characteristically slapping the foot down again – Unilateral foot drop This suggests a mechanical or compressive neu- ropathy of the common peroneal nerve or L5 root – Bilateral foot drop, Due to a symmetrical distal neuropathy of the toxic, or steppage gait metabolic, or familial type, as in alcoholic neuropathy or Charcot–Marie–Tooth progressive peroneal atrophy Heel-drop gait Due to paralysis of the tibial nerve, patients are unable to plantarflex the foot, although dorsiflexion is possible Flail-foot gait Due to complete sciatic palsy, patients are unable to either dorsiflex or plantarflex the foot Toe-walking gait Because of tight heel cords, the child has a limited dorsiflexion of the foot to about 90! This type of gait is seen in Duchenne’s muscular dystrophy, in spastic diplegia, and in autistic or other retarded children Sensory gaits Painful sole or hyper- When patients set the foot down, they put as little esthetic gait weight on it as possible and raise it as soon as possible, hunching the shoulders – Unilateral In Morton’s metatarsalgia, a painful neuroma of an in- terdigital nerve, or gout – Bilateral In painful distal neuropathies of toxic, metabolic or al- coholic in origin Radicular pain gait or Compression of the L5 root from a herniated disk antalgic gait causing extreme pain radiating into the big toe, ag- gravated by coughing, sneezing, or straight leg rais- ing. The back is lordotic, and when patients walk they do not put any weight on the painful leg and take stiff, slow, short strides, with no heel strike. The trunk tilts slightly to the side opposite the pain Tsementzis, Differential Diagnosis in Neurology and Neurosurgery © 2000 Thieme All rights reserved. A pathognomonic gait seen often in autistic and other retarded children, who develop repetitive, self-stimu- lating mannerisms resembling a variety of flipping- hand gaits Tabetic or dorsal Resembles a double foot drop. Seen in patients with column or sensory tabes dorsalis, in whom a syphilitic infection causes ataxic gait degeneration of the dorsal columns of the spinal cords. Patients lift the knees high and slap the feet down, placing them irregularly due to sensory ataxia. When standing, they need to use visual cues to avoid swaying and falling over Blind person’s gait The slow, deliberate, and searching steps of a blind person are characteristic, and should not confuse an experienced examiner Cerebellar gaits Unilateral cerebellar A unilateral cerebellar lesion, most likely caused by gait neoplasm, infarct, or demyelinating disease, causes ipsilateral cerebellar signs, with the patient presenting dystaxia of volitional movements (veering or falling in one direction) and of volitionally maintained postures, producing a reeling gait Bilateral cerebellar gait Bilateral cerebellar signs imply a toxic, metabolic or fa- miliar disorder. Dystaxia of the legs and gait, with little or no dystaxia of the arms, and no dysarthria or nys- tagmus, suggests a rostral vermis syndrome, most commonly secondary to alcoholism. Truncal ataxia alone implies a flocculonodular lobe or caudal vermian lesion, often a fourth ventricular tumor Spastic gaits Hemiplegic gait Patients circumduct the affected leg, dragging the toe and placing the ball down without a heel strike, with the ipsilateral arm held in partial flexion or, less often, flaccidly at the side Spastic gaits Patients walk with stiff legs, not clearing the floor with either foot, giving the appearance of wading through water because they have to work against the spastic opposition of their own muscles, as if walking in thick, sticky mud; the knees tend to rub together in a scis- soring action Pure spastic or para- A pure spastic paraplegic gait without sensory deficits, plegic gait developing after birth, implies a corticospinal tract disorder, as in familial spastic paraplegia Tsementzis, Differential Diagnosis in Neurology and Neurosurgery © 2000 Thieme All rights reserved. Types of Stance and Gait 267 Spastic diplegic gait Patients affected by diplegic cerebral palsy have small and short legs in contrast to normally developed chest, shoulders, and arms. In spastic diplegia, there is severe spasticity in the legs, minimal spasticity in the arms, and little or no deficit in speaking or swallowing; whereas in double hemiplegia, there is pseudobulbar palsy and more arm weakness than leg weakness Spastic–ataxic gait If, in addition to spasticity, the disease impairs the dorsal columns or cerebellum, as in spinocerebellar degeneration or multiple sclerosis, patients have a wider-based, unsteady gait and take irregular steps Basal ganglia gaits Marche à petits pas Elderly patients with small vessel disease due to arte- (gait with little steps) riosclerosis, appearing as multiple lacunar infarcts in the basal ganglia, develop a characteristic gait with shuffling, short steps, and are unable to lift the feet from the ground. Progress in walking ceases if the patient tries to speak (they are unable to walk and talk or chew gum at the same time) Parkinsonian gait Patients with degeneration of the substantia nigra or neuroleptic medication toxicity rise and walk slowly with short steps, lack any arm swing, turn en bloc like a statue rotating on a pedestal, and have a tremor when at rest, which disappears during intentional movement Festinating gait When patients are pushed after prior warning, they move forward or backward with tiny steps of increas- ing speed and decreasing length, as if chasing the center of gravity, and they may fall over Choreiform gait When patients with Huntington’s or Sydenham’s chorea walk, the play of finger and arm movements increases, or may even appear clearly for the first time. Random missteps mar the evenness of the strides, as the choreiform twitches supervene Spastic–athetoid gait A combination of athetosis and moderate spastic diplegia or double hemiplegia secondary to perinatal hypoxic damage of the basal ganglia and thalamus has the characteristics of spastic gait, associated with slow, writhing movements of fingers and arms, which tend to increase during walking Equinovarus dystonic Dystonia may initially manifest in a child as an inter- gait mittent inturning of the foot that impedes walking, while in later stages dystonic truncal contortions and tortipelvis may cause the trunk to incline strongly for- ward Tsementzis, Differential Diagnosis in Neurology and Neurosurgery © 2000 Thieme All rights reserved. When starting to walk, patients makes several efforts to move the feet, appearing somewhat puzzled—as if searching for lost motor engrams, or the right buttons to press in order to set off Dancing bear gait The effort to progress may only result in stepping on the spot, as if trying to free the feet from thick, sticky mud Apraxic gait When patients do manage to make progress, the feet cling to the floor as if magnetized Psychiatric gaits Astasia–abasia The patient tilts, gyrates, and undulates all over the place, proving unwittingly—by not falling during this marvelous demonstration of agility—that strength, balance, coordination, and sensation must still be in- tact Sexual behavior and The gait is characteristic of and diagnostic of the bio- biological orientation logical and behavioral state of a person’s brain gaits Heterosexual male– female gait Tsementzis, Differential Diagnosis in Neurology and Neurosurgery © 2000 Thieme All rights reserved. Lancet 2: 81–84, 1974 Pediatric Coma Scale Response Score Eye opening Spontaneous 4 To voice 3 To pain 2 No response 1 Best motor response Flexes / extends 4 Withdraws 3 Hypertonic 2 Flaccid 1 Best verbal response Cries 3 Spontaneous respiration 2 Apneic 1 Tsementzis, Differential Diagnosis in Neurology and Neurosurgery © 2000 Thieme All rights reserved. Venous occlusion – Trauma (closed head injury) – Epilepsy and postictal states – Neoplasm! Gliomatosis cerebri Toxic and metabolic encephalopathy Exogenous – Sedatives or psycho-! Tsementzis, Differential Diagnosis in Neurology and Neurosurgery © 2000 Thieme All rights reserved. The Unconscious Patient 271 – Uremic coma Kidney failure – Hepatic coma Liver failure – CO2 narcosis Pulmonary failure – Electrolyte distur-! Porphyria Anoxia Hypoxic Decreased blood PO2 and O2 content – Pulmonary disease – Decreased atmos- pheric oxygen Anemic Decreased blood O2 content, PO2 normal – CO poisoning – Anemia – Methemoglobinemia Ischemia Decreased cardiac out- Congestive heart failure put – Cardiac arrest – Severe cardiac ar- rhythmias – Aortic stenosis Decreased systemic peri- pheral resistance – Blood loss and hypo- volemic shock – Syncopal attack – Anaphylactic shock Intracranial vessel dis- ease – Increased vascular! Fat embolism Tsementzis, Differential Diagnosis in Neurology and Neurosurgery © 2000 Thieme All rights reserved.

People across the socioeconomic scale need our services and we must tai- lor these to the needs of the specific patients and populations we are priv- ileged to serve generic vardenafil 10 mg without a prescription erectile dysfunction 40 over 40, treat discount vardenafil 20 mg amex whey protein causes erectile dysfunction, coach, and consult with. To enhance the efficiency and effectiveness of treatment, the therapist must be comfortable dis- cussing money and financial concerns and knowledgable about the val- ues, behaviors, and needs of people of all social classes. He or she should be able to be empathic with their interpretation of their life story in order to enable them to be willing to shift their view of the world, to becoming more optimistic and self-directing; able to utilize available resources or reestablish severed family connections; willing to take more responsibil- ity for their own behavior and attempting to make the changes they want instead of expecting others to do so for them; able to reevaluate their needs and goals in terms of an evolving clearer sense of what gives mean- ing and purpose to their life; overcome their pervasive sense of isolation, emptiness, or anger; and able to earn the money they need or access what is available from community resource funds to live decently; or to be gen- erous and charitable if they have the financial wherewithal to give for the benefit of others. Laura and Michael had been married for 15 years and had two children, Caitlyn (14) and Josh (8). Laura returned to work full-time, taking the night shift as a nurse on an emergency ward. A crisis occurred when Michael discovered that Laura had a short-lived affair with a doctor with whom she worked. She also re- vealed that she had been unhappy in the marriage for some time and was considering separation. Michael was extremely anxious, distraught, and unsure that he could even forgive or transcend the affair. The affair had made Laura much more aware of how deeply dissatisfied she was with the lack of intimacy in the marriage and what she characterized as Michael’s passivity and emotional unavailability. They had one brief separation early in the marriage and two sessions of couple counseling at that time, which they felt helped their com- munication, but didn’t resolve their basic personality and value differ- ences. Having divorced once, Laura felt she could manage on her own, but was very ambivalent about declaring she wanted a divorce, since she was fearful of hurting Michael and their children. She wanted the options for separation and divorce to be a part of the marital therapy. Their children were doing well and were relatively unaware of the depth of their parents’ problems. The first four sessions involved taking a detailed individual, mari- tal, and familial history in which it was learned that Laura felt smothered and overprotected as an only child. To the consternation of her family, at age 20 she moved to Las Vegas to cohabit with and marry an older man. His gambling addiction debts precipitated the divorce as well as her realization that she had married too young, essentially to escape her family. She moved back to her hometown, met Michael at work, and dated for a year before marrying. Michael, a quiet man and a contrast to Laura’s first husband, was attracted to her outgoing personality and ability to make friends easily. The transition to divorce therapy is not as clear as a therapist might like, often involving a fairly lengthy period in which the clients go back and forth about whether to stay together. Finally, a time comes when the therapist can offer the observation that the issue the couple is discussing has been repeat- edly addressed without resolution and that neither party has desired to or 424 SPECIAL ISSUES FACED BY COUPLES After five months of separation, Laura and Michael came in together to see the therapist again. She had received a promo- tion at work and was feeling more secure financially as well as relieved emotionally. Their daughter appeared to be adjusting well, although her se- mester grades had taken a dip as she spent increasing amounts of time with her peers. Laura worried that Michael turned to their daughter too much for emotional support, and Michael complained that Laura was too lenient with the children, perhaps in response to her own parents’ strictness. The session was spent exploring appropriate boundaries with the children and the need to establish and maintain consistent, authoritative parenting by both. They finally agreed to a therapeutic referral for their son and also to investigate a school program for kids going through divorce. A begin- ning understanding of their mutual interlocking problems with intimacy and identity, which were unresolved when they went into the marriage, was also addressed. Michael had made some progress in individual therapy in understanding the causes for his passivity and inability to show his feel- ings, his anger at his parents’ stoicism, and his emotional constriction in the marriage. He had hoped to get the unconditional love he never received from his parents from Laura, yet he could not reciprocate that love. Laura, however, was reluctant to explore the roots of her unsuccessful marital partnerships and the pattern of problems that she had replicated in her first and second marriages. She was more content to simply say she had made mistakes and to focus on the present. Following key tasks of restructuring and adjustment engendered by di- vorce, therapy can focus more on ego reparation tasks: regaining self-esteem and confidence, coping with loneliness and aloneness, and building a social support network of friends and intimates. These tasks are immeasurably helped if the person has gained a realistic understanding of the causes of the divorce, his or her contributions, and unraveling the patterns of uncon- scious childhood strivings in the marriage and other relationships as well as family of origin issues.

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Pain to their problems as "hurting vardenafil 20 mg visa erectile dysfunction devices diabetes," "aching buy cheap vardenafil 10 mg on-line injections for erectile dysfunction forum," or some other can have a substantial impact on caregiver strain and description. Because of the frequency with which problems are often identified, the physical exam Pain assessment is the most important part of pain man- should concentrate on the musculoskeletal and nervous agement. Tender points of inflammation, muscle spasm, tify the underlying source and associated physiologic pain and trigger points should be sought. Observation of mechanisms to choose the most effective treatment and abnormal posture, gait impairment, and limitations in maximize patient outcomes. Pain management is most range of motion may trigger a need for physical therapy effective when the underlying cause of pain has been and rehabilitation. A sys- assessment is the need to evaluate acute pain that may tematic neurologic exam is also important to identify indicate life-threatening injury and distinguish this from potential sources of neuropathic pain. For chronic pain in which weakness, atrophy, abnormal reflexes, or sensory impair- the cause is not reversible or only partially treatable, a ments may indicate peripheral or centeral nervous multidimensional or multidisciplinary evaluation may system injury. Among those with cognitive impairment or presence of a Charcot joint, orthostatic hypotension, difficulty reporting pain, other clinicians, family, and impaired gastric emptying, or incontinence may indicate caregivers may be helpful in providing a more accurate autonomic nervous system dysfunction that can imply description. It is important to assess functional status to identify Elders may tend to underreport pain, despite substantial self-care deficits and formulate treatment plans that functional impairment. Functional problems and multiple sources of pain make assessment status can also represent an important outcome measure more difficult. Functional status can be sensory function, and denial and avoidance behaviors evaluated from information taken from the history and may all contribute to underreporting. Pain History and Physical Examination A brief psychologic and social evaluation is also impor- Assessment of pain should begin with a thorough history tant. Depression, anxiety, social isolation, and disengage- and physical examination to help establish a diagnosis of ment are all common in patients with chronic pain. There underlying disease and form a baseline description of is a significant association between chronic pain and pain experiences. The history should include questions to depression, even when controlling for overall health and elicit: when the pain started; what events or illnesses coin- functional status. Psychologic evaluation Unidimensional scales consist of a single item that should also include consideration of anxiety and coping usually relates to pain intensity alone. Anxiety is common among patients with acute and usually easy to administer and require little time or train- chronic pain and requires extra time and frequent reas- ing to produce reasonably valid and reliable results. Chronic pain often have found widespread use in many clinical settings to requires effective coping skills for anxiety and other monitor treatment effects and for quality assurance indi- emotional feelings that can be learned. It is important to remember that therapy, biofeedback, or some psychoactive medications unidimensional pain scales often require framing the pain may be necessary for developing and maintaining effec- question appropriately for maximum reliability. Subjects tive coping strategies as well as management of major should be asked about pain in the present tense (here and psychiatric complications. For example, the interviewer should frame the explored for availability and involvement of family and question, "How much pain are you having right now? It has been shown that the family’s and Alternatively, the interviewer can ask, "How much pain informal caregivers’ involvement can have a substantial have you had over the last week? Need for frequent cognitive impairment have shown that pain reports transportation, administration of pain treatments, and requiring recall are influenced by pain at the moment. Pain Assessment Scales A variety of pain scales are available to help categorize and quantify the magnitude of pain complaints. Results Pain Assessment in Persons with of these scales are also helpful in documenting and com- Cognitive Impairment municating pain experiences. It is helpful to evaluate pain using an appropriate pain scale initially and periodically Cognitive impairment, Alzheimer’s disease, stroke, or to maximize treatment outcomes. Results can be dementia can present substantial challenges to pain recorded in flow chart or graph, making it easy to iden- assessment. Fortunately, it has been shown that pain tify stability or changes in pain over time. Because there reports from those with mild to moderate cognitive are no objective biologic markers or "gold standards," the impairment are no less valid than other patients with validity of pain scales relies largely on face value, corre- normal cognitive function.

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Venous with the most important predisposition to DVT—a thromboembolism in association with prolonged air travel vardenafil 10 mg without prescription kidney transplant and erectile dysfunction treatment. Dermatol previous history of evidence of DVT—were excluded vardenafil 10 mg line erectile dysfunction caused by nerve damage, Surg 1996; 22: 637–41. Lancet between acute hypobaric hypoxia and activation of coagulation in 2000; 356: 1492–93. Prog 22 Kniffin WD Jr, Baron JA, Barrett J, Birkmeyer JD, Cardiovasc Dis 1975; 17: 259–70. Thromboembolic Risk compression ultrasonography and clinical examination for the Factors. Overview of results of lower extremity venous US evaluation in patients without known risk randomized trials in general, orthopaedic, and urologic surgery. Acute calf vein thrombosis: for deep venous thrombosis after total knee athroplasty. The use of power Doppler ultrasound in the in the follow-up of acute calf vein thrombosis. Rates of venous thrombosis after 28 Robertson PL, Goergen SK, Waugh JR, Fabiny RP. Lancet compression ultrasound in the diagnosis of calf deep venous 1986; 2: 143–46. Thrombosis of the measurement of D-dimer as a diagnostic aid in suspected venous muscular calf veins-reference to a syndrome which receives little thromboembolism: an overview. For the chosen article, work through the critical appraisal sheet on the next pages and then: (a) decide whether the internal validity of the study is sufficient to allow firm conclusions (all studies have some flaws; but are these flaws bad enough to discard the study? Ideally, subjects should be selected randomly from the Te Methods section should tell you how patients were population of interest. If another method is used (eg selected and allocated to groups and whether or not volunteers), inclusion/exclusion criteria should be clearly randomisation was concealed. Group allocation should be random, and concealed, preferably using a centralised computer (large multicentre trials) or an independent person (small trials). Tis trial: YES NO UNCLEAR Comment: (b) Were the groups similar at the start of the trial? If the randomisation process worked, the groups should be Te Results section should have a table of ‘baseline similar. If there are differences, the paper should indicate if characteristics’ comparing groups on a number of they are statistically significant. If not, there should be a description of the group characteristics in the Results text. Apart from the intervention, the patients should be treated Te Methods section should have a follow-up schedule the same (eg additional treatments or tests). Tis trial: YES NO UNCLEAR Comment: (d) Were all the subjects that entered the trial accounted for at the end? Losses to follow-up should be minimal (preferably less than Te Results section should show how many patients were 20%, but if few subjects have the outcome of interest even randomised, how many were included in the analysis and smaller losses can bias results). It is ideal if both the subjects and investigators are unaware Te Methods section will indicate if subjects were aware of the treatment (double blinded trial). Blinding is less of their treatment group (ie if a placebo was used), how critical if the outcome is objective (eg death) than if it is the outcome was assessed and whether the assessors were subjective (eg symptoms or function). Tis trial: YES NO UNCLEAR Comment: (b) Were the outcomes measured the same way for all groups? It is important to measure outcomes in exactly the same Te Methods section should describe how the outcomes way for both the treatment and control groups. To eliminate a ‘placebo effect’ in the outcomes measured, Te Methods section will describe the treatment of the control group should receive a placebo treatment. P-value Confidence interval (CI) CONCLUSION Internal validity: Results: 82 General practice Funding: This work was undertaken while MJ was visiting 9 Burnett MG, Grover SA.

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A randomized clinical trial of outpatient comprehen- of impact of model of integrated care and case management sive geriatric assessment coupled with a intervention to for older people living in the community cheap 20 mg vardenafil erectile dysfunction when drugs don't work. Keeler EB buy vardenafil 20mg low cost erectile dysfunction 29, Robalino DA, Frank JC, Hirsch SH, Maly RC, home care services on hospital use. Comprehensive Geriatric Assessment and Systems Approaches to Geriatric Care 203 33. In: Grosel C, Hamilton M, controlled trial of nurse case management of frail older Koyano J, Eastwood S, eds. Albert A variety of cognitive disorders occur with increasing is much that a geriatrician can do to identify the presence frequency as people age; these include progressive de- of cognitive dysfunction and see that it is properly menting disorders, acute confusional states, and cognitive assessed. Epidemi- ologic studies indicate that approximately 15% of the population over 65 years of age suffers from some form 1 Interview with Patient of dementia. However, the probability of having a dementing disorder increases dramatically with age. Data There are two sources of information concerning the concerning the prevalence of dementia in a community- cognitive status of patients: (1) patients themselves and dwelling population indicate that between the ages of 65 (2) patients’ families. Unless a family member has and 74 years the prevalence of dementia ranges from 2% approached the physician with concerns about the to 3%; this increases to 22% to 23% among those persons patient’s cognitive function, it is not likely a family 75 to 84 years and to 47% to 48% among those persons 2 member will be routinely involved in a geriatric assess- aged 85 years and older. Therefore, the physician is initially limited to to the incidence and prevalence of acute confusion in information that is obtainable from the patient. Several studies have information can be most easily gathered in two ways: (1) reported that 25% to 35% of hospitalized geriatric from an interview of the patient in the course of con- patients on a general medical service who are cognitively ducting a medical evaluation and (2) from brief mental intact at admission develop acute confusion. There are few systematic studies of the preva- lence of cognitive disorders secondary to psychiatric Medical Examination syndromes, but numerous clinical reports state that their prevalence is greater among elderly patients than young In the course of a routine medical examination, there is patients. Because the bidity and mortality, and although only some of them can most common causes of cognitive decline in elderly be completely reversed with treatment, appropriate man- patients produce a memory disorder (specifically a dif- agement can substantially improve the quality of life and ficulty with learning and retaining new information), reduce the development of secondary conditions. Thus, it greatest emphasis should be placed on ascertaining infor- is in the best interests of the patient if one can become mation about the memory function of the patient. This increasingly attuned to the possible presence of cognitive may be accomplished by a discussion of current events. For focuses on the role of neuropsychologic testing in the one patient; it may be politics, for another, sports, and assessment of cognitive dysfunction in elderly patients, for another, the stage of the planting season. If there is a particularly as it applies to the geriatrician, because there particularly dramatic event in the news that most people 205 206 M. There- plane crash), this may be useful for persons of diverse fore, it is ideal if this can be supplemented by a brief test backgrounds. Exam (MMSE),7 the Blessed Dementia Scale (BDS),8 Many patients in the early stages of dementing disorder and the Short Portable Mental Status Questionnaire can make general all-purpose remarks that appear to be (SPMSQ). Language prob- Of these, the MMSE has most commonly been used in lems are important to assess because they are common in clinical settings. The patient’s comprehension ability can be ability, set shifting) in a simple and straightforward evaluated during a medical examination with relative manner. In addition, the wide use of the MMSE in epi- ease because the patient is generally asked to perform demiologic studies has yielded cutoff scores that facilitate tasks (e. Speech fluency also is relatively easy to experimental settings, but epidemiologic data are limited. Patients who are nonfluent have an effortful and Finally, the extensive use of the MMSE has produced halting quality to their speech. Substantive words, such widespread familiarity with its scoring system, facilitating as nouns and verbs, are present, but small connective communication among clinicians. In general, Naming ability also can be assessed in the course of scores greater than 26 are considered to be excellent and conversation. Mildly impaired hesitates over names of objects or persons and may patients typically obtain scores of 18 to 26, moderate attempt to circumvent the difficulty in a variety of ways impairment is reflected by scores of 11 to 18, and severe (e. If naming problems are is generally recommended as indicative of cognitive dys- suspected, a further evaluation can be carried out by function; however, the application of this cutoff value using common objects at hand. Very familiar objects, such must be modified by knowledge of the educational level as a watch or a door, are easy to name. For example, patients with a substantial with a relatively severe naming problem will have diffi- amount of education can experience a considerable culty with them. In general, however, parts of objects are amount of cognitive decline before a score of 23 is harder to name (e.

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