A 77 year old woman attends her GP surgery accompanied by her daughter, who is concerned about her memory. This has been getting incrementally worsening over the last 1-2 years, but around 1 month ago deteriorated again to the point that it is now difficult to complete day-to-day activities like cooking and shopping. For the last month, there have been instances of difficulty with fine motor tasks, such as buttoning shirts and tying shoelaces. She has a past medical history of diabetes and hypertension and had a myocardial infarction 15 years ago. She has stopped smoking since her myocardial infarction, and only drinks two glasses of wine every weekend.

Both the patient and her daughter deny any personality changes or hallucinations.

Which of the following is the most likely diagnosis?

Options:
explanation: Frontotemporal dementia (FTD) typically presents with profound behavioural and personality changes, often affecting social conduct. Hallucinations are also not uncommon. These are not seen in this patient. In FTD, the cognitive decline is usually gradual and not associated with stepwise progression. This patient also has significant vascular risk factors that increase the likelihood of cerebrovascular disease, making vascular dementia more likely.
name: Frontotemporal dementia
label: c
answer: no
explanation: The stepwise progression of symptoms, where there are noticeable declines in cognitive function followed by periods of stability, is more characteristic of vascular dementia. Alzheimer's disease typically exhibits a gradual, progressive decline in cognitive function without distinct, stepwise changes. Furthermore, Alzheimer's disease is primarily associated with memory, cognitive and behavioural changes and may not manifest with motor symptoms in the early stages. This patient also has significant vascular risk factors that increase the likelihood of cerebrovascular disease, making vascular dementia more likely.
name: Alzheimer's disease
label: b
answer: no
explanation: This is the correct answer. The patient has diabetes and a history of hypertension and myocardial infarction, all of which are significant vascular risk factors for the development of vascular dementia. These conditions increase the risk of cerebrovascular disease and damage to the brain's blood vessels, which can lead to vascular dementia. The patient's condition deteriorating in an incremental or stepwise nature is a classic feature of vascular dementia, as vascular events such as small infarcts can lead to several small, sudden declines in cognitive function.
name: Vascular dementia
label: a
answer: yes
explanation: Visual hallucinations and fluctuating attention and alertness are more common in Lewy body dementia, which are not described in this vignette. A stepwise progression is less typical of dementia with Lewy bodies, which tends to have a more fluctuating course. This patient also has significant vascular risk factors that increase the likelihood of cerebrovascular disease, making vascular dementia more likely.
name: Dementia with Lewy bodies
label: d
answer: no
explanation: First of all, this patient does not have an excessive alcohol intake as she drinks around 5 units every week, which is less than the recommended 14 unit limit. Although alcohol-related dementia could also present with memory problems, her moderate alcohol intake makes alcohol-related dementia highly unlikely. Given her old age, diagnosis of a form of dementia due to age-related neuropathologic changes is much more likely. The patient's vascular risk factors and step-wise progression points towards a diagnosis of vascular dementia.
name: Alcohol related dementia
label: e
answer: no

Correct answer: a