Case 1 :

An eighty-one year old man is brought to the physician's office by his son and daughter-in-law.   The father, Mr. Ryan, lives in the lower level of a two story, two family home.   The son and his wife live upstairs.   They are concerned that he is increasingly forgetful.   Recently, he became lost on a walk in his neighborhood.   Mr. Ryan is relatively unconcerned and says:   AMy kids worry too much about me.   After all, I am eighty years old.   What do you expect?@   Mr. Ryan denies depressed mood, difficulty   sleeping, ruminative thoughts, concerns about death, or thoughts about taking his life.   On further questioning, Mr. Ryan's son describes that over the last two years his father has had increasing difficulty managing his finances, caring for his apartment, and preparing meals.   He has trouble remembering the names of his three grandchildren and has forgotten all family birthdays over the past year.   He will spend most of the morning reading the paper and seems to reread the sports pages several times.

Medical history is unremarkable except for bilateral cataract replacements.   There are no prescribed   medications.   There is no history of depression.   Social history is remarkable for owning the house where his son and daughter live, a remote smoking history but no cigarettes for over thirty years, and one to two drinks a night.   Mr. Ryan's wife died ten years ago.  

Physical exam is remarkable for a pleasant older man, laughing and winking as his son mentions his concerns.   Vital signs include a regular pulse at 70 and a blood pressure of 140/80.   Pertinent physical findings include no evidence of head trauma, full extraocular motions, clear lungs, a regular cardiac rhythm with a soft systolic murmur heard at the right second intercostal space, no carotid bruits, a benign abdominal exam with guaiac negative stool, and a firm prostate nodule.   Neurologic exam reveals normal cranial nerve findings, motor strength 5/5 in all extremities, sensory intact to light touch with decreased vibratory sense in both legs, and normal cerebellar exam, gait, and reflexes.   Toes are bilaterally down-going on plantar stimulation.

A Folstein Mini-Mental State Exam reveals a total score of 23.   Mr. Ryan missed the day, date, year, and place.   He was attentive and able to spell WORLD backwards.   He remembered 0/3 objects after 5 minutes.