Is it a 'senior moment' or early dementia? Addressing memory concerns in older patients

Medical considerations
Just as all domains of cognition are correlated to some degree, the overall health status of a person influences evaluation of memory. Variables, such as fatigue, test anxiety, mood, motivation, visual and auditory acuity, education, language fluency, attention, and pain, affect test performance. In addition, clinician rapport and the manner in which tests are administered must be considered.

Depression can mimic MCI. A depressed patient often has poor expectations of himself and slowed thinking, and might exaggerate symptoms. He might give up on tests or refuse to complete them. His presentation initially could suggest cognitive decline, but depression is revealed when the clinician pays attention to vegetative signs (insomnia, poor appetite) or suicidal ideation. There is growing evidence that subjective complaints of memory loss are more frequently associated with depression than with objective measures of cognitive impairment.^13,14

Other treatable conditions can present with cognitive change (the so-called reversible dementias). A deficiency of vitamin B₁₂, thiamine, or folate often is seen because quality of nutrition generally decreases with age. Hyponatremia and dehydration can present with confusion and memory impairment. Other treatable conditions include:

• cerebral vasculitis, which could improve with immune suppressants
• endocrine diseases, which might respond to hormonal or surgical treatment
• normal pressure hydrocephalus, which can be relieved by surgical placement of a shunt.

Take a complete history. What exactly is the nature of the patient or caregiver’s complaint? You need to attempt to engage the patient in conversation, observing his behavior during the evaluation. Is there notable delay in response, difficulty in attention and focus, or in understanding questions?

The content of speech is an indicator of the patient’s information processing. Ask the patient to recite as many animals from the jungle as possible. Most people can come up with at least 15. The person with MCI will likely name fewer animals, but may respond well to cueing, and perform better in recognition (eg, pictures or drawings) vs retrieval. When asked to describe a typical day, the patient may offer a vague, nonchalant response eg, “I keep busy watching the news.” This kind of response may be evidence of confabulation; with further questioning, he is unable to identify current issues of interest.

Substance abuse. It is essential that clinicians recognize that elders are not exempt from alcohol and other drug abuse that affects cognition. Skilled history taking, including attention to non-verbal responses, is indicated. A defensive tone, rolling of eyes, or silent yet affirmative nodding are means by which caregivers offer essential “clues” to the provider.

A quick screening tool for the office is valuable; many clinicians are most familiar with the Mini-Mental State Examination or the Saint Louis University Mental Status Examination, which are known to be sensitive in detecting memory problems and other cognitive defects. As we noted, the MoCA is now recommended for differentiating more subtle changes of MCI.^10,15 It is important to remember that common conditions such as an urinary tract infection or trauma after anesthesia for routine procedures such as colonoscopy can cause cognitive impairment. Again, eliciting history from a family member is valuable because the patient may have forgotten vital data.

A good physical exam is important when evaluating for dementia. Look for any neurologic anomaly. Check for disinhibition of primitive reflexes, eg, abnormal grasp or snout response or Babinski sign. Compare the symmetry and strength of deep tendon reflexes. Look for neurologic soft signs. Any pathological reflex response can be an important clue about neurodegeneration or space-occupying lesions. We recall seeing a 62-year-old man whose spouse brought him for evaluation for new-onset reckless driving and marked inattention to personal hygiene that developed over the previous 3 months. On examination, he appeared disheveled and had a dull affect, although disinhibited and careless. His mentation and gait were slowed. He denied distress of any kind. Frontal release signs were noted on exam. An MRI revealed a space-occupying lesion of the frontal lobe measuring 3 cm wide with a thickness of 2 cm, which pathology confirmed as a benign tumor.

Always check for arrhythmia and hypertension. These are significant risk factors for ischemic brain disease, multiple-infarct stroke, or other forms of vascular dementia. A shuffling gait suggests Parkinson’s disease, or even Lewy body dementia, or medication-related conditions, for example, from antipsychotics.

Take a medication history. Many common treatments for anxiety and insomnia can cause symptoms that mimic dementia. Digitalis toxicity results in poor recall and confusion. Combinations of common medicines (antacids, antihistamines, and others) compete for metabolic pathways and lead to altered mental status. Referencing the Beers List¹⁶ is valuable; anticholinergics, benzodiazepines, and narcotic analgesics are of special concern. The latter could still be useful for comfort care at the end of life.