Intended for healthcare professionals

Endgames Case Report

Diagnostic dilemma in an elderly woman

BMJ 2011; 342 doi: (Published 06 April 2011) Cite this as: BMJ 2011;342:d969
  1. Farooq Khan, specialist registrar in old age psychiatry12,
  2. Martin Curtice, consultant old age psychiatrist1
  1. 1Centre for Ageing and Mental Health, Staffordshire University, Stafford, UK
  2. 2Birmingham and Solihull Mental Health NHS Foundation Trust, Birmingham, UK
  1. Correspondence to: F Khan farooqkhandr{at}

A woman in her 70s with basic school education first presented to the mental health centre with an obsession with her pillows—she used to compulsively straighten creases in pillow covers. A diagnosis of obsessive-compulsive disorder was made.

Within a few months her obsessive symptoms had changed to psychotic symptoms with delusional intensity. Amisulpride was prescribed for a few months with some benefit. Less than a year after her original presentation her husband reported that she was displaying some odd behaviour: she often stood or sat in a place and stared at the walls or anything in the surrounding area in a “trance like state” for minutes at a time, which professionals suspected were absence seizures.

Electroencephalography showed abnormal focal paroxysmal beta rhythmic activity, from the left temporal region initially but later also independently from the right side. Her score on the mini-mental state examination was 22/30, and computed tomography of her head revealed cerebral atrophy more prominent than would be expected for a patient of her age. Magnetic resonance imaging of her head showed fronto-parietal vascular changes and focal bi-temporal atrophy.

The patient’s condition deteriorated, and her cognitive decline became obvious. She had problems with recent memory, difficulty finding words, made up new words, and was disorientated in time, place, and person. She also exhibited a gross decline in comparison with her premorbid personality. She was admitted to hospital on the basis of these symptoms.


  • 1 What is the most likely diagnosis and the differential diagnoses?

  • 2 What is the association between seizures and cognitive impairment?

  • 3 What further investigations would you use to clarify the diagnosis?

  • 4 What is the comprehensive medical management of this patient?


1 What is the most likely diagnosis and the differential diagnoses?

Short answer

The main diagnosis is mixed vascular and Alzheimer’s dementia. Differential diagnoses should include subcortical vascular dementia, complex partial seizures, dementia …

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