Tips from Other Journals

Previous | Next

Evaluating Older Adults with Mild Memory Problems

Memory loss is common in older adults and is usually noted by either the adults or their family members and friends. Persons with clinically meaningful memory loss usually show delayed recall or impaired ability to remember recently learned information. Another consideration in patients with memory loss is a problem in another cognitive area that manifests as a memory problem. Language impairment or inattention related to depression are two of a number of causes that may present as memory problems. Karlawish and Clark reviewed the evaluation of older adults with mild memory complaints.

Normal aging resulting in frontal lobe decline can cause memory lapses, but performance of daily activities is not impaired. Mild cognitive impairment, with symptoms falling between those of normal aging and those of dementia, may represent a predementia state, with an increased likelihood of progression to Alzheimer's disease.

Memory loss that impairs function suggests neurodegenerative dementia, which is defined as a decline in two or more cognitive domains. Common causes of dementia include, in order of likelihood, Alzheimer's disease, frontotemporal dementia, and dementia with Lewy bodies. Early Alzheimer's disease manifests as problems with retaining new information and difficulty with cueing to help jog the memory. Social withdrawal or other mood or behavior changes can begin mildly and may reflect difficulties in dealing with an unfamiliar environment. Disease progression is characterized by word hesitancy and circumlocutions, although language comprehension is less impaired.

The evaluation of memory problems starts with a history focused on changes in the patient's ability to perform instrumental activities of daily living. These activities, such as shopping, cooking, managing money, using the telephone, and taking medications, are good indicators of cognitive function. Interviewing a knowledgeable informant helps the physician determine the nature and severity of the patient's impairments. Physicians should use judgment in assessing this information so the impairment is not overestimated or underestimated.

Sequence of Tests for Efficient Office-Based Assessment of Cognition in Patients with Cognitive Symptoms and Suspected Alzheimer's Disease The rightsholder did not grant rights to reproduce this item in electronic media. For the missing item, see the original print version of this publication.

Useful methods of assessment include closer observation by a family member or friend and a brief, standardized cognitive and affective test using an abbreviated set of questions (see accompanying table on page 1850) or the Mini-Mental State Examination. Use of a depression scale can help screen for concomitant depression. Treatment of depression might improve functional status, although antidepressants with anticholinergic side effects that could worsen cognitive function should be avoided.

In the physical examination, the physician should evaluate the patient for focal neurologic deficits that may represent vascular dementia, gait disorder (parkinsonism) with or without altered levels of alertness, and visual hallucinations that may suggest dementia with Lewy bodies, or frontal and behavior signs that suggest frontotemporal dementia. Diagnostic testing should include a complete blood count, basic blood chemistries, thyroid function testing, and determination of the vitamin B₁₂ level. As cognitive function deteriorates, magnetic resonance imaging is appropriate to distinguish vascular etiologies from other causes. The clinical significance of cortical atrophy is unclear.

Treatment of dementia is based on the cause and the impact of the cognitive changes. Patients with Alzheimer's disease may benefit from vitamin E and a cholinesterase inhibitor to slow disease progression. Arrangements should be made to lessen the negative impact of cognitive declines by enlisting the help of family members and support organizations. Other issues that should be addressed include caregiver's needs, changes in treatment, and placement in a long-term care facility, when required.

In the same journal, Clark and Karlawish review diagnostic and therapeutic strategies for Alzheimer's disease. They discuss the on-going development of diagnostically specific biomarkers and new treatments.

RICHARD SADOVSKY, M.D.

Karlawish JH, Clark CM. Diagnostic evaluation of elderly patients with mild memory problems. Ann Intern Med March 4, 2003;138:411-9, and Clark CM, Karlawish JH. Alzheimer disease: current concepts and emerging diagnostic and therapeutic strategies. Ann Intern Med March 4, 2003;138:400-10.

Previous | Next