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Intermittent, worsening confusion recently developed in an year-old man. His daughter brings him to the office for evaluation. The patient lives alone and is self-sufficient; he cooks, gardens, and manages his own finances. For the past 2 days, however, he has become increasingly forgetful. For example, he misplaced his car keys, got lost when he returned home from a walk, and did not recognize his son-in-law. His gait has also been unsteady recently. Yet at times he seems to be his former self.

The patient denies fever, cough, chest pain, dyspnea, palpitations, GI symptoms, headache, vision problems, weakness, paresthesias, seizures, syncope, and bladder dysfunction. His weight has been steady. About 3 days earlier, he fell when he got up in the middle of the night, but he sustained no external injuries. The patient has hypertension and moderately severe degenerative joint disease of the hips, knees, and shoulders.