Intended for healthcare professionals

Endgames Case Report

A woman with forgetfulness and falls

BMJ 2011; 343 doi: (Published 24 November 2011) Cite this as: BMJ 2011;343:d7412
  1. Louise Pealing, general practitioner,
  2. Steve Iliffe, professor of primary care for older people
  1. 1Research Department of Primary Care and Population Health, Royal Free Hospital, London NW3 2PF, UK
  1. Correspondence to: S Iliffe s.iliffe{at}

A 69 year old woman presented to her general practitioner with a six month history of occasional falls and fluctuating forgetfulness and attention. Although she reported no difficulties with names and dates she needed help with taking drugs and preparing meals. She had also had two episodes of apparent visual hallucinations of a woman standing at the foot of her bed. Her sleep behaviour had been poor for many years, with frequent strong physical jerks and motion while sleeping. She had no symptoms of altered or low mood. Her medical history included hypothyroidism, osteoporosis, and cholesteatoma, and she was being investigated for a mixed fibre peripheral sensory neuropathy of unknown cause. Current drugs included levothyroxine, calcitriol, calcium carbonate-colecalciferol, and lansoprazole. She did not drink alcohol and was a non-smoker.

On examination she was fully orientated in time and place and her AMTS (abbreviated mental test score) was 10/10 with an MMSE (mini-mental state examination) score of 26/30. Her blood pressure, temperature, and cardiovascular and respiratory examinations were normal. Cranial nerve examination was normal with no primitive reflexes or supranuclear gaze palsy. Tone and power were normal throughout all limbs, as were sensation and reflexes in the upper limbs. The lower limbs showed reduced vibration and pin prick sensation to the mid-shin bilaterally, and joint position sense was limited to large movements. She showed no evidence of bradykinesia or apraxia, but her gait was ataxic in keeping with her peripheral sensory impairment.


  • 1 What is the differential diagnosis?

  • 2 What investigations would you do?

  • 3 How should this patient be managed?


1 What is the differential diagnosis?

Short answer

Given the patient’s fluctuating forgetfulness and alertness, the differential diagnosis must include causes of delirium and dementia. The most common causes of delirium in this age group are infection, metabolic and nutritional disturbances (including hypoxia and hypoglycaemia), cerebral haematomas caused …

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