Differential Diagnosis
- Single most likely diagnosis
- B) Dementia, Lewy body: This diagnosis is the most likely due to the combination of cognitive decline (difficulty judging distances, forgetfulness), visual hallucinations, and fluctuations in mental status. The patient's symptoms of increasing difficulty with daily tasks, such as driving and job performance, along with the presence of visual hallucinations, are characteristic of Dementia with Lewy bodies (DLB). The episodes of kicking violently in bed, which the patient reports as also occurring in his dreams, could be indicative of REM sleep behavior disorder, a condition often associated with DLB.
- Other Likely diagnoses
- Alzheimer's disease: While the patient presents with cognitive decline and hallucinations, the presence of visual hallucinations early in the disease course and the fluctuating cognitive symptoms are more suggestive of DLB. However, Alzheimer's cannot be ruled out without further evaluation.
- Vascular dementia: Given the patient's history of hypertension, vascular dementia could be considered, especially if there were evidence of stepwise decline or focal neurological signs. However, the prominent visual hallucinations and REM sleep behavior disorder-like symptoms are less typical for vascular dementia.
- Do Not Miss diagnoses
- Normal Pressure Hydrocephalus (NPH): Although less likely, NPH can present with cognitive decline, gait disturbances, and urinary incontinence. The patient's difficulty with judging distances could be interpreted as a gait issue, but the absence of reported urinary incontinence and gait disturbance makes this less likely.
- Chronic subdural hematoma: This condition can cause fluctuating cognitive symptoms, but it would typically be associated with a history of trauma, which is not mentioned in the scenario.
- Rare diagnoses
- Creutzfeldt-Jakob disease: This is a rare, rapidly progressive dementia that can include visual hallucinations, but it typically progresses much more quickly than described, and myoclonus is a more common feature.
- Prion diseases other than Creutzfeldt-Jakob: These are rare and would have differentiating features such as prominent ataxia or myoclonus, not prominently featured in this case.
- Akathisia (A), Essential tremor (C), Hemiballismus (D), and Vascular Parkinsonism (E): These options do not fit well with the patient's presentation of cognitive decline, visual hallucinations, and the specific nature of his motor symptoms, making them less likely diagnoses.