A 75-year-old woman comes to the office due to increasing forgetfulness and difficulty concentrating. Her memory has always been sharp, but over the last several months her friends have noticed that she has been forgetful. The patient used to visit them regularly at the community center, but now she prefers to stay home most days. She mentions difficulty with focusing and easy fatigability. She falls asleep earlier than usual and has frequent nighttime awakenings. The patient's husband died from a stroke 6 months ago, and she has been living alone since. Her children live far away and have not been checking up on her regularly.
Vital signs are normal. Mini-Mental State Examination score is 26/30, with difficulties in delayed recall, concentration, and attention. Physical examination is unremarkable. Laboratory studies, including vitamin B₁₂ levels and thyroid function, are normal.
Which of the following is the best next step in management of this patient?

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11ec193a_98b1_0be0_853d_b1529ae8cb2b_MD0002_00 When older adults present with cognitive impairment, mood and affect should be closely examined to determine if underlying depression may be causing these deficits. This patient has no known medical problems, and results of her physical examination and screening laboratory studies are normal. Her recent cognitive decline and associated symptoms of social withdrawal, fatigue, and sleep disturbance in the setting of bereavement raise concern for major depressive disorder. Late-life depression frequently presents with reversible cognitive impairment (pseudodementia) and neurovegetative features rather than subjective report of mood changes. Validated depression screening tools such as the PHQ-9 and geriatric depression scale can also help diagnose depression in older patients. When the underlying depression is treated, the cognitive impairment often fully resolves. (Choice B) Although interviewing family members can often yield valuable information about behavioral changes and functional impairment, this patient lives alone and does not see her family regularly. Asking the patient about her mood is more important. (Choice C) Neuroimaging is most useful for ruling out other reversible causes of dementia (eg, subdural hematoma, normal-pressure hydrocephalus, treatable cancer), which are unlikely in the absence of focal neurologic findings. Although structural neuroimaging should be considered in the evaluation of all patients with dementia, this patient's cognitive deficits are more likely secondary to depression, which should be ruled out first. (Choice D) This patient's Mini-Mental State Examination score of 26/30 makes dementia less likely as scores <24/30 are highly sensitive and specific for dementia. Assessing the patient for depression would take precedence over performing additional cognitive testing. (Choice E) Although normal aging is associated with some memory loss and changes in sleep pattern, this patient is functionally impaired and is becoming more socially isolative. She requires further evaluation and treatment. Educational objective: Major depressive disorder in older patients can present with reversible cognitive changes rather than depressed mood. Older patients with new-onset cognitive impairment should routinely be assessed for depression. __________ References: Depression and cognition in the elderly. (http://www.ncbi.nlm.nih.gov/pubmed/25581234) Diagnosis and treatment of depression and cognitive impairment in late life. (http://www.ncbi.nlm.nih.gov/pubmed/25655026)

A 75-Year-Old Woman Comes to the Office Due to Increasing