A 73-year-old woman is brought to the office by her daughter due to worsening memory. The patient began having difficulty with her memory 2 years ago but was mostly independent until recently. Over the past 2 months, she has gotten lost several times while driving locally. She can no longer be allowed to cook for herself because she has frequently forgotten to turn off the stove. The patient has hypertension, gastroesophageal reflux disease, and alcohol use disorder. Her medications include lisinopril and ranitidine. Family history is negative for dementia. Vital signs and physical examination are within normal limits. TSH and vitamin B₁₂ levels are normal. Montreal Cognitive Assessment is 22 out of 30 (normal: ≥26). Which of the following is the most appropriate next step in management of this patient?

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Explanation: 11ec2b69_bfe5_0394_8f63_51fdcb7df770_MD0005_00 This patient's progressive cognitive decline and resultant functional impairment (ie, deficits in activities of daily living) are concerning for a diagnosis of dementia (also known as major neurocognitive disorder). Before a diagnosis of a specific dementing syndrome can be made, reversible causes of dementia must be ruled out. Routine laboratory testing includes complete blood count, complete metabolic panel, TSH, and vitamin B₁₂ levels; specific at-risk populations should receive additional testing. This patient's workup should include a folate level as her alcohol use disorder places her at risk for folate deficiency and resultant cognitive impairment. Although thiamine deficiency and subsequent Wernicke-Korsakoff syndrome may also lead to cognitive decline in patients with alcoholism, suspected cases are generally treated empirically as the utility of laboratory tests for thiamine is low. (Choice A) Apolipoprotein E polymporphisms are associated with Alzheimer dementia. However, genetic testing is currently not recommended for the routine evaluation of dementia as it exposes patients to the psychological harms of false positives and false negatives without providing significant clinical utility. (Choice C) The most common neurological manifestations of Lyme disease are meningitis, radiculoneuritis, and cranial neuropathy. Testing for Lyme disease would be low yield in this patient without the presence of a symptom constellation consistent with the illness or a specific history (eg, tick bite). (Choices D and E) Testing for syphilis and vitamin D deficiency is currently recommended in only specific at-risk populations, such as patients with a known syphilis exposure or those suffering from nephrotic syndrome, respectively. Educational objective: The initial laboratory workup to rule out reversible causes of cognitive impairment includes complete blood count, complete metabolic panel, TSH, and vitamin B₁₂ levels. Selective testing of folate and for syphilis or vitamin D deficiency is indicated for patients with specific risk factors; patients with alcoholism are at increased risk for folate deficiency. ₁₂ References: Evaluation of suspected dementia. (http://www.ncbi.nlm.nih.gov/pubmed/22010769) Dementia for the primary care provider. (http://www.ncbi.nlm.nih.gov/pubmed/28797371) Modifiable predictors of dementia in mild cognitive impairment: a systematic review and meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/25698435)

A 73-Year-Old Woman Is Brought to the Office by Her