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The history of memory problems is usually one of slow progression without landmark occurrences. If specific dates of worsening are noted, the possibility of a vascular dementia increases. Family history may be significant. One inherited dementia, Huntington's disease, has a clear autosomal dominant pattern of inheritance.

General physical examination does not determine the diagnosis of dementia as findings are largely nonspecific or normal. 912 The presence of focal neurologic signs may suggest vascular dementia or a mass lesion. Increased motor tone and other extrapyramidal signs such as rigidity or a movement disorder may suggest Parkinson's disease. Mental status testing should be performed as outlined previously ( T.a,bJ.e,,22.1:2, Ia.ble.,2.2..1:3, and Table,221:4).

Controversy exists about diagnostic testing in patients with typical features of Alzheimer's type dementia. Again, about 10 to 20 percent of patients may have a treatable form of dementia (see T.┬žble.,.2.2.1-Z). The American Academy of Neurology has published a practice parameter that recommends complete blood count; serum electrolytes; calcium, glucose, BUN, creatinine, and liver function tests; thyroid function tests; serum B 12; and serology for syphilis. Other laboratory tests that are optional, but that may be helpful in certain circumstances, include sedimentation rate, serum folate level, HIV testing, chest x-ray, and urinalysis. 9 Neuroimaging such as CT or MR should be considered in every patient. CSF analysis is not recommended in every case but should be performed if clinical suspicion of a condition with an inflammatory CSF exists. Local practice patterns and the patient's social support will influence whether tests are done as inpatient or in the ED or other outpatient setting.

Diagnosis of probable vascular dementia not only requires cognitive dysfunction but also signs of cerebrovascular disease upon neurologic examination. The relationship between stroke and cognitive decline must be temporally related with dementia within 3 months of the stroke or abrupt deterioration of memory and other cognitive abilities. A fluctuating stepped course suggests vascular dementia. 13

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