Educational objective: Elderly patients with depression often present with cognitive impairment that can mimic other causes of dementia. The impairment is usually reversible with treatment of the underlying depressive disorder.

A 63-year-old man is brought to the office by his daughter due to recurrent falls. According to his daughter, the patient has lost his balance and fallen several times over the past 6 months. He has not sustained serious injuries. She has also noticed some "shaking" of his right hand that is most apparent at rest The patient has lived alone since his wife died 5 years ago and still shops, cooks, and cleans independently. Blood pressure is 141/68 mm Hg and pulse is 72/min. Neurologic examination shows mild rigidity of the limb muscles that is most prominent on the right side with a slow, shuffling gait The patient is prescribed medication for his symptoms but returns to the office 4 weeks later reporting "disturbing visions of strangers creeping around corners of his apartment" On examination, he is alert and scores 27 /30 on the Montreal Cognitive Assessment (normal: ;::26).

Educational objective: Medications used in the treatment of Parkinson disease may cause hallucinations. Dopamine agonists and, to a lesser extent, levodopa are associated with this adverse effect

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A 58-year-old woman comes to the physician due to difficulty walking. Over the last several weeks she has also experienced bilateral foot numbness and tingling. She was diagnosed with advanced Hodgkin lymphoma 2 months ago and is currently undergoing chemotherapy containing bleomycin, doxorubicin, and vincristine. Her other medical problems include type 2 diabetes and hypertension. Physical examination shows bilateral weakness on dorsiflexion of the feet and loss of pain and temperature sensation affecting both toes. Knee jerk reflexes are 2+ bilaterally but ankle jerk reflexes are absent

Educational objective: Chemotherapy-induced peripheral neuropathy typically presents as a symmetric, distal, sensory neuropathy that spreads in a stocking-glove pattern. Common causative agents include platinum-based medications (eg, cisplatin}, taxanes (eg, paclitaxel), and Vinca alkaloids (eg, vincristine }.

A 71-year-old man comes to the ·office due to worsening low back pain. The patient is having significant pain with movement that is limiting his activity, as well as nocturnal pain that is disrupting his sleep. He has had no lower extremity weakness or numbness and no bladder or bowel dysfunction. He is taking ibuprofen 3-4 times a day, and it is not controlling his pain. The patient has a history of prostate cancer and takes leuprolide. He also received palliative radiotherapy for multiple lumbar spine metastases several months ago. Temperature is 37 C (98.6 F), blood pressure is 140/86 mm Hg, and pulse is 88/min. Lower extremity motor strength, deep tendon reflexes, and sensation are normal.

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