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The earliest signs of dementia due to degenerative disease may be so subtle as to escape the notice of the most discerning physician An observant relative of the patient or an employer may become aware of a certain lack of initiative or lack of interest in work, a neglect of routine tasks, or an abandonment of pleasurable pursuits Initially, these changes may be attributed to depression, fatigue, or boredom More often, gradual development of forgetfulness is the most prominent early symptom Proper names are no longer remembered, to a far greater extent than can be attributed to mild cognitive impairment or benign senescent forgetfulness (see further on) Dif culty in balancing a checkbook and making change becomes evident The purpose of an errand is forgotten, appointments are not kept, a recent conversation or social event has been overlooked The patient may ask the same question repeatedly over the course of a day, having failed to retain the answers that were previously given Later it becomes evident that the patient is easily distracted by every passing incident He no longer nds it possible to think about or discuss a problem with his customary clarity or to comprehend all aspects of complex situations The patient s judgment and ability to make proper deductions and inferences from given premises are greatly reduced One feature of a situation or some relatively unimportant event may become a source of unreasonable concern or worry Tasks that require several steps cannot be accomplished, and all but the simplest directions cannot be followed The patient may get lost, even along habitual routes of travel Dayto-day events are not recalled, and perseveration or impersistence in speech, action, and thought becomes evident In yet other instances, an early abnormality may be in the nature of emotional instability, taking the form of unreasonable outbursts of anger, easy tearfulness, or aggressiveness Frequently a change in mood becomes apparent, deviating more toward depression than elation Apathy is common Some patients are grumpy and irascible; a few are cheerful and facetious The direction of the mood change is said to depend on the patient s previous personality rather than on the character of the disease, but one can think of glaring exceptions Excessive lability of mood may also be observed for example, easy uctuation from laughter to tears on slight provocation A few patients come to the physician with physical complaints, the most common being dizziness, a vague mental fogginess, and nondescript headaches The patient s inability to give a coherent account of his symptoms bears witness to the presence of a dementia Sometimes the mental failure is brought to light more dramatically by a severe confusional state attending a febrile illness, a concussive head injury, an operative procedure, or the administration of some new medicine; this is the beclouded dementia discussed below and in Chap 20 As noted there, the fam-.

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discern early in the disease process In particular, a proportion of patients thought to have Alzheimer disease are found to have another type of degenerative cerebral atrophy, such as Lewy-body disease, progressive supranuclear palsy, Huntington disease, Parkinson disease, corticobasal degeneration, Pick disease, and frontotemporal dementia (all described in Chap 39) Or such patients have one of a variety of other processes, such as multi-infarct dementia or hydrocephalus alone or in combination with one of the other disorders Of special importance is the fact that approximately 10 percent of patients who are referred to a neurologic center with a question of dementia prove to have a potentially reversible psychiatric or metabolic disorder In the following pages we consider the prototype dementing syndromes They are observed most frequently with degenerative diseases of the brain (Chap 39) and less often as part of other categories of disease (vascular, traumatic, infectious, demyelinative, etc), which are considered in their appropriate chapters Mild Cognitive Impairment From several sources it has become apparent that many individuals have memory complaints that are mild and do not interfere with daily functioning but are still disporportionate for the patient s age and education It is is often dif cult to differentiate this less intrusive problem, which is ostensibly due to the normal process of aging, from dementia The former condition has been called mild cogntive impairment, age-associated memory impairment, and, in the past, benign senescent forgetfulness, as discussed in Chap 29, on aging When other aspects of mental functioning are affected, terms such as aging-associated cognitive decline are used De ning the boundaries of such a condition has proved problematic, and determining the risk of progression to a dementing illness even more so There is a further problem introduced by the premise that highly intelligent individuals would have to drop considerably on intelligence and memory tests to be identi ed as below certain age-adjusted norms However, a notion has evolved in which Alzheimer disease and mild cognitive impairment exist in a spectrum (see Burns and Zaudig), and one of the main values to identifying such patients in a presymptomatic period of Alzheimer disease is the potential for early institution of treatment In most studies, 10 to 20 percent per year of such affected patients will be found to have acquired Alzheimer disease A num-.

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