{"id":3306,"date":"2024-06-05T16:37:00","date_gmt":"2024-06-05T16:37:00","guid":{"rendered":"https:\/\/www.osmosis.org\/blog\/?p=3306"},"modified":"2026-02-19T17:35:47","modified_gmt":"2026-02-20T01:35:47","slug":"usmle-step-1-question-of-the-day-cognitive-decline","status":"publish","type":"post","link":"https:\/\/www.osmosis.org\/blog\/usmle-step-1-question-of-the-day-cognitive-decline","title":{"rendered":"USMLE\u00ae Step 1 Question of the Day: Cognitive decline"},"content":{"rendered":"<div id=\"ez-toc-container\" class=\"ez-toc-v2_0_80 ez-toc-wrap-center counter-hierarchy ez-toc-counter ez-toc-custom ez-toc-container-direction\">\n<div class=\"ez-toc-title-container\">\n<p class=\"ez-toc-title\" style=\"cursor:inherit\">In This Article<\/p>\n<span class=\"ez-toc-title-toggle\"><a href=\"#\" class=\"ez-toc-pull-right ez-toc-btn ez-toc-btn-xs ez-toc-btn-default ez-toc-toggle\" aria-label=\"Toggle Table of Content\"><span class=\"ez-toc-js-icon-con\"><span class=\"\"><span class=\"eztoc-hide\" style=\"display:none;\">Toggle<\/span><span class=\"ez-toc-icon-toggle-span\"><svg style=\"fill: #999;color:#999\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" class=\"list-377408\" width=\"20px\" height=\"20px\" viewBox=\"0 0 24 24\" fill=\"none\"><path d=\"M6 6H4v2h2V6zm14 0H8v2h12V6zM4 11h2v2H4v-2zm16 0H8v2h12v-2zM4 16h2v2H4v-2zm16 0H8v2h12v-2z\" fill=\"currentColor\"><\/path><\/svg><svg style=\"fill: #999;color:#999\" class=\"arrow-unsorted-368013\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"10px\" height=\"10px\" viewBox=\"0 0 24 24\" version=\"1.2\" baseProfile=\"tiny\"><path d=\"M18.2 9.3l-6.2-6.3-6.2 6.3c-.2.2-.3.4-.3.7s.1.5.3.7c.2.2.4.3.7.3h11c.3 0 .5-.1.7-.3.2-.2.3-.5.3-.7s-.1-.5-.3-.7zM5.8 14.7l6.2 6.3 6.2-6.3c.2-.2.3-.5.3-.7s-.1-.5-.3-.7c-.2-.2-.4-.3-.7-.3h-11c-.3 0-.5.1-.7.3-.2.2-.3.5-.3.7s.1.5.3.7z\"\/><\/svg><\/span><\/span><\/span><\/a><\/span><\/div>\n<nav><ul class='ez-toc-list ez-toc-list-level-1 ' ><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-1\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-1-question-of-the-day-cognitive-decline\/#The_correct_answer_to_todays_USMLE%C2%AE_Step_1_Question_is%E2%80%A6\" >The correct answer to today&#8217;s USMLE\u00ae Step 1 Question is&#8230;<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-2\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-1-question-of-the-day-cognitive-decline\/#Incorrect_Answer_Explanations\" >Incorrect Answer Explanations<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-3\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-1-question-of-the-day-cognitive-decline\/#Main_Explanation\" >Main Explanation<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-4\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-1-question-of-the-day-cognitive-decline\/#Major_Takeaway\" >Major Takeaway<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-5\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-1-question-of-the-day-cognitive-decline\/#References\" >References<\/a><\/li><\/ul><\/nav><\/div>\n\n<p class=\"wp-block-paragraph\"><em>This USMLE Step 1 Question of the Day involves a <strong>60-year-old woman<\/strong> with <strong>progressive cognitive decline, fluctuating mental clarity, mild tremors, slowed movements, <\/strong>and <strong>balance issues<\/strong>. Based on these clinical features, what&#8217;s the <strong>most likely <\/strong>diagnosis<\/em>?<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">A <strong>60-year-old woman<\/strong> comes to the clinic accompanied by her daughter for a follow-up appointment for <strong>cognitive decline<\/strong>. During the past <strong>2 years<\/strong>, the daughter says the patient has been having <strong>difficulty managing her accounts<\/strong> and is <strong>often confused<\/strong>. She has some \u201cgood days\u201d when she manages the household and some \u201cbad days\u201d when she is <strong>confused <\/strong>and <strong>needs assistance<\/strong>.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">The patient\u2019s partner passed away three years ago from a <strong>myocardial infarction<\/strong>, and in the past few months, her daughter <strong>found the patient talking to him as though he is in the room.<\/strong> About 6 months ago, the patient started having a <strong>mild resting tremor in her right hand<\/strong>. Since then, the patient\u2019s <strong>movements have slowed down<\/strong>, and she often <strong>loses balance<\/strong>. Vitals are within normal limits. No <strong>orthostasis <\/strong>is seen. On physical examination, the patient has a <strong>flat affect<\/strong>, and a <strong>resting tremor <\/strong>is noted in the right hand. The patient <strong>walks slowly with small steps<\/strong> and has a <strong>kyphotic posture<\/strong>. <\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Which of the following is the <em>most likely<\/em> diagnosis?&nbsp;<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>A.&nbsp;Progressive supranuclear palsy<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>B.&nbsp;Parkinson disease<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>C.&nbsp;Frontotemporal dementia&nbsp;<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>D.&nbsp;Dementia with Lewy bodies<\/strong><strong>E.&nbsp;Multiple system atrophy&nbsp;<\/strong><\/p>\n\n\n\n<p class=\"has-text-align-center wp-block-paragraph\"><em>Scroll down for the correct answer!<\/em><\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"The_correct_answer_to_todays_USMLE%C2%AE_Step_1_Question_is%E2%80%A6\"><\/span>The correct answer to today&#8217;s USMLE\u00ae Step 1 Question is&#8230;<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>D.&nbsp;Dementia with Lewy bodies<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Before we get to the Main Explanation, let&#8217;s look at the incorrect answer explanations. Skip to the bottom if you want to see the correct answer right away!<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Incorrect_Answer_Explanations\"><\/span>Incorrect Answer Explanations<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>A.&nbsp;Progressive supranuclear palsy<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:<\/strong>&nbsp;<strong>Progressive supranuclear palsy (PSP)<\/strong> is a <strong>neurodegenerative disease<\/strong> characterized by <strong>personality and behavior changes, parkinsonism, loss of balance <\/strong>and <strong>vertical eye palsy<\/strong>. The absence of <strong>vertical eye palsy<\/strong> and <strong>marked personality changes<\/strong> favors another diagnosis.&nbsp;&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>B.&nbsp;Parkinson disease<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:<\/strong>&nbsp;If <strong>Parkinson motor symptoms <\/strong>are present for more than 1 year before <strong>dementia<\/strong>, the diagnosis is <strong>Parkinson disease dementia<\/strong>. If dementia appears <strong>before or together with the motor symptoms, or less than a year after<\/strong>, the diagnosis is considered <strong>dementia with Lewy bodies<\/strong>. This patient had signs of dementia a year and a half before motor signs.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>C.&nbsp;Frontotemporal dementia<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:<\/strong>&nbsp;Frontotemporal dementia, formerly known as <strong>Pick disease<\/strong>, is characterized by <strong>early personality and behavior changes or aphasia<\/strong>. Patients with <strong>frontotemporal dementia<\/strong> may also have <strong>associated movement disorders (e.g. parkinsonism)<\/strong>. This patient has not had marked personality changes. Additionally, parkinsonism, if present, occurs very late in the course of the disease.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>E.&nbsp;Multiple system atrophy<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:<\/strong>&nbsp;Multiple system atrophy (MSA) is a <strong>group of neurodegenerative syndromes <\/strong>with similar <strong>underlying brain pathology <\/strong>that are characterized by <strong>parkinsonism, autonomic dysfunction, cerebellar abnormalities, <\/strong>and <strong>corticospinal degeneration.<\/strong> This patient has <strong>no autonomic dysfunction<\/strong> (e.g. orthostatic hypotension), which favors another diagnosis. Additionally, in contrast to idiopathic Parkinson disease, patients with MSA have <strong>preserved cognitive function<\/strong>.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Main_Explanation\"><\/span>Main Explanation<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">This patient is presenting with <strong>progressive dementia, cognitive fluctuation (\u201cgood\u201d and \u201cbad\u201d days), <\/strong>and <strong>recent onset of parkinsonian signs,<\/strong> all favoring the diagnosis of <strong>dementia with Lewy bodies (DLB).<\/strong>&nbsp;&nbsp;&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">DLB is a common type of degenerative dementia. In addition to dementia, a patient with DLB <strong>must have at least 2 of the 4 core features<\/strong>, including:&nbsp;<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li><strong>cognitive fluctuations&nbsp;<\/strong><\/li>\n\n\n\n<li><strong>visual hallucinations&nbsp;<\/strong><\/li>\n\n\n\n<li><strong>rapid eye movement (REM) sleep behavior disorder&nbsp;<\/strong><\/li>\n\n\n\n<li><strong>parkinsonism, which is characterized by the 4 clinical signs of tremor, rigidity, akinesia, and postural instability (TRAP)&nbsp;<\/strong><\/li>\n<\/ul>\n\n\n\n<p class=\"wp-block-paragraph\">Patients typically show an early decline in <strong>executive function<\/strong> (e.g. calculations), and <strong>visuoperceptual ability<\/strong> (e.g. missing traffic signs). The diagnosis of DLB is based upon the <strong>presence of core clinical features, history, and physical examination<\/strong>. MRI will likely show <strong>nonspecific diffuse cortical atrophy.<\/strong> The hallmark of the disease is the presence of <strong>Lewy bodies on pathological examination<\/strong> of the brain; these are <strong>eosinophilic intracytoplasmic inclusions<\/strong> containing <strong>aggregated alpha-synuclein<\/strong> in the <strong>deep cortical layers<\/strong>.&nbsp;&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">The differentiation of Parkinson disease from DLB is <strong>typically based on the timeline in which symptoms occur.<\/strong> If Parkinsonian motor symptoms are present for more than 1 year before dementia, the diagnosis is Parkinson disease dementia, whereas if dementia occurs <strong>concomitantly with or before parkinsonian motor signs<\/strong>, or no more than a year after onset, it is considered dementia with Lewy bodies.&nbsp;&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Several <strong>neurodegenerative conditions <\/strong>may present with the <strong>classic signs of PD (e.g., tremor, rigidity)<\/strong> which may be hard to differentiate. These conditions are often referred to as <strong>Parkinson-plus syndromes <\/strong>and include <strong>multiple system atrophy, progressive supranuclear palsy, and DLB.<\/strong> Each has unique features that may help in establishing the diagnosis.&nbsp;<\/p>\n\n\n\n<figure class=\"wp-block-image size-full\"><img loading=\"lazy\" decoding=\"async\" width=\"934\" height=\"334\" src=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/image_29596b.png\" alt=\"PARKINSON-PLUS SYNDROMES\nCharacterized by the typical Parkinson motor symptoms (tremors, rigidity, bradykinesia\/akinesia, postural instability) PLUS the additional differentiating clinical features:\n\nMultiple System Atrophy\nAutonomic dysfunction (e.g., postural hypotension, erectile dysfunction)\n\nProgressive Supranuclear Palsy\nVertical gaze palsy and marked personality changes\n\nCorticobasal Degeneration\nAlien limb phenomenon (the feeling that the limb does not belong to the subject or that it has a will of its own)\n\nDementia with Lewy Bodies:\nEarly onset of dementia, with hallucinations\/psychosis as well as cognitive fluctuations.\" class=\"wp-image-3308\" srcset=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/image_29596b.png 934w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/image_29596b.png?resize=300,107 300w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/image_29596b.png?resize=768,275 768w\" sizes=\"auto, (max-width: 934px) 100vw, 934px\" \/><\/figure>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Major_Takeaway\"><\/span>Major Takeaway<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">Dementia with Lewy bodies&nbsp;is a <strong>neurodegenerative condition characterized by&nbsp;dementia<\/strong>&nbsp;and <strong>at least&nbsp;two<\/strong>&nbsp;of the following features:&nbsp;<strong>cognitive fluctuations,&nbsp;visual hallucinations,&nbsp;rapid eye movement (REM) sleep behavior disorder, <\/strong>and&nbsp;<strong>parkinsonism<\/strong>. In contrast, if parkinsonism symptoms are present for more than a year before the onset of dementia, it is officially classified as <strong>Parkinson disease dementia<\/strong>.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"References\"><\/span>References<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Parkinson-Plus Syndromes: Clues to Diagnosis, Multiple System Atrophy, Progressive Supranuclear Palsy. (2019, November 9). Retrieved from&nbsp;<a href=\"https:\/\/emedicine.medscape.com\/article\/1154074-overview\" target=\"_blank\" rel=\"noreferrer noopener\">https:\/\/emedicine.medscape.com\/article\/1154074-overview<\/a>.&nbsp;<\/li>\n\n\n\n<li>Postuma RB, Berg D, Stern M, et al. MDS clinical diagnostic criteria for Parkinson&#8217;s disease. Mov Disord. 2015;30(12):1591-1601. doi:10.1002\/mds.26424&nbsp;<\/li>\n<\/ul>\n\n\n\n<figure class=\"wp-block-image size-full\"><a href=\"https:\/\/www.osmosis.org\/ultimate-guide\/usmle-step-1\"><img loading=\"lazy\" decoding=\"async\" width=\"700\" height=\"250\" src=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/image_c15690.png\" alt=\"\" class=\"wp-image-3309\" srcset=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/image_c15690.png 700w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/image_c15690.png?resize=300,107 300w\" sizes=\"auto, (max-width: 700px) 100vw, 700px\" \/><\/a><figcaption class=\"wp-element-caption\"><em><sub>The United States Medical Licensing Examination (USMLE\u00ae) is a joint program of the Federation of State Medical Boards (FSMB\u00ae) and National Board of Medical Examiners (NBME\u00ae). Osmosis is not affiliated with NBME nor FSMB.&nbsp;<\/sub><\/em><\/figcaption><\/figure>\n\n\n\n<p class=\"wp-block-paragraph\"><em><strong>Want more USMLE\u00ae Step 1 practice questions?<\/strong> Try Osmosis by Elsevier today! Access your&nbsp;<em><a href=\"https:\/\/www.osmosis.org\/login?type=create\" target=\"_blank\" rel=\"noreferrer noopener\"><strong>free trial<\/strong><\/a><\/em>&nbsp;and find out why millions of current and future clinicians and caregivers love learning with us.<\/em><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><\/p>\n","protected":false},"excerpt":{"rendered":"<p>An older woman presents with fluctuating cognition, visual hallucinations, and parkinsonism. What diagnosis best explains her symptoms?<\/p>\n","protected":false},"author":202,"featured_media":3307,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_jetpack_newsletter_access":"","_jetpack_dont_email_post_to_subs":false,"_jetpack_newsletter_tier_id":0,"_jetpack_memberships_contains_paywalled_content":false,"_jetpack_feature_clip_id":0,"_jetpack_memberships_contains_paid_content":false,"footnotes":"","jetpack_post_was_ever_published":false},"categories":[27,20,1366,1369,44],"tags":[1955,1957,1960,1959,245,1954,1961,1956,664,1958],"class_list":["post-3306","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-medicine","category-exam-prep","category-questions","category-step-1-questions","category-step-1","tag-cognitive-decline","tag-dementia-diagnosis","tag-dementia-with-lewy-bodies","tag-neurodegenerative-disorders","tag-nursing-education","tag-parkinson-disease-dementia","tag-parkinsonism","tag-rem-sleep-disorder","tag-usmle-step-1","tag-visual-hallucinations"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v23.6 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>USMLE\u00ae Step 1 Question of the Day: Cognitive decline - Osmosis Blog<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-1-question-of-the-day-cognitive-decline\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"USMLE\u00ae Step 1 Question of the Day: Cognitive decline - Osmosis Blog\" \/>\n<meta property=\"og:description\" content=\"An older woman presents with fluctuating cognition, visual hallucinations, and parkinsonism. What diagnosis best explains her symptoms?\" \/>\n<meta property=\"og:url\" content=\"https:\/\/www.osmosis.org\/blog\/usmle-step-1-question-of-the-day-cognitive-decline\" \/>\n<meta property=\"og:site_name\" content=\"Osmosis Blog\" \/>\n<meta property=\"article:published_time\" content=\"2024-06-05T16:37:00+00:00\" \/>\n<meta property=\"article:modified_time\" content=\"2026-02-20T01:35:47+00:00\" \/>\n<meta property=\"og:image\" content=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/2024-09-18T103811.818.webp\" \/>\n\t<meta property=\"og:image:width\" content=\"1080\" \/>\n\t<meta property=\"og:image:height\" content=\"1080\" \/>\n\t<meta property=\"og:image:type\" content=\"image\/webp\" \/>\n<meta name=\"author\" content=\"Marina Horiates Kerekes, MD &amp; Team\" \/>\n<meta name=\"twitter:card\" content=\"summary_large_image\" \/>\n<script type=\"application\/ld+json\" class=\"yoast-schema-graph\">{\"@context\":\"https:\/\/schema.org\",\"@graph\":[{\"@type\":[\"Article\",\"BlogPosting\"],\"@id\":\"https:\/\/www.osmosis.org\/blog\/usmle-step-1-question-of-the-day-cognitive-decline#article\",\"isPartOf\":{\"@id\":\"https:\/\/www.osmosis.org\/blog\/usmle-step-1-question-of-the-day-cognitive-decline\"},\"author\":{\"name\":\"Marina Horiates Kerekes, MD &amp; 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