A 68-year-old White woman presents to her primary care provider for routine follow-up. She reports feeling confused, slowing down mentally and physically since her visit 6 months ago, and having increased trouble completing daily tasks. She reports that it is hard and "too much" for her to manage her household, especially with keeping up with her bills and personal affairs, like taking her blood pressure medication.

The patient lives alone and has two children, a son and a daughter. Her son is accompanying her on today's visit and reports a marked change in his mother's behavior and mood within the past year. The patient was once happy, even-tempered, and mild-mannered but has become anxious and is often aggressive, with moods that fluctuate easily and quickly. On a recent visit, her daughter noticed that the patient appeared dirty, unkempt, and in need of a bath. She became very aggressive and violent when prompted to bathe.

The patient has a history of hypertension, with current blood pressure of 185/90 mm Hg because of poor medication adherence. Her medical history is otherwise unremarkable. On examination, she appears tired and somewhat restless and anxious. She has difficulty with attention and concentration. She is not able to recall times of aggression or wandering and when raised becomes defensive. She bumps into the chair and the exam table when getting up and walking across the room and has difficulty tying her shoes, opening the door, and putting her bag into a drawer when asked. Laboratory testing is performed (complete blood count, comprehensive metabolic panel, thyroid panel) and reveals nothing remarkable.