A 65-year-old woman is brought to the office by her family due to increasing forgetfulness over the past year. The patient previously had trouble remembering where she left her keys or glasses, and lately she has had difficulty recalling familiar names. She says, "I'm just getting older and slowing down," but her daughter became concerned when her mother couldn't remember the steps to make a favorite dish that she had previously cooked from memory for years. The patient has a history of well-controlled hypertension. She does not use tobacco but has 2 glasses of wine daily. Her husband unexpectedly died of a myocardial infarction a year ago. The patient's mother died of Alzheimer disease in her 80s. Blood pressure is 130/85 mm Hg and pulse is 85/min. The patient is alert, oriented, and cooperative. Muscle strength, sensation, deep tendon reflexes, and gait are normal. Which of the following is the best next step in management of this patient?

Question

A 65-year-old woman is brought to the office by her family due to increasing forgetfulness over the past year.  The patient previously had trouble remembering where she left her keys or glasses, and lately she has had difficulty recalling familiar names.  She says, "I'm just getting older and slowing down," but her daughter became concerned when her mother couldn't remember the steps to make a favorite dish that she had previously cooked from memory for years.  The patient has a history of well-controlled hypertension.  She does not use tobacco but has 2 glasses of wine daily.  Her husband unexpectedly died of a myocardial infarction a year ago.  The patient's mother died of Alzheimer disease in her 80s.  Blood pressure is 130/85 mm Hg and pulse is 85/min.  The patient is alert, oriented, and cooperative.  Muscle strength, sensation, deep tendon reflexes, and gait are normal.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d292_694a_bc81_33c336bdbae1_MD0003_00 This patient's year-long history of increasing forgetfulness and executive dysfunction is concerning for mild cognitive impairment (MCI). The first step in evaluation of suspected MCI is to perform a standardized cognitive examination using a cognitive screening tool such as the Montreal Cognitive Assessment (MoCA) or mini-mental state examination (MMSE). The MoCA is a widely used 30-point scale that assesses orientation, attention/concentration, language, delayed word recall, and visuospatial/executive function. Scores of <26/30 on the MoCA are suggestive of clinically significant cognitive impairment. For many of these tools, patients in the classic study cohorts were generally age 65-80 with ~12 years of education and were tested in their native language. If the results of the MoCA suggest clinically significant cognitive impairment, the patient should undergo a workup for potentially reversible causes of cognitive impairment, which includes depression screening, laboratory evaluation (eg, vitamin B₁₂level, TSH, complete blood count, complete metabolic panel), and neuroimaging (eg, MRI). ₁₂ (Choice A) The apolipoprotein E (APOE) gene is associated with greater risk for late-onset Alzheimer disease (AD), but the test's positive predictive value is low and of limited clinical utility at this time. For example, up to 40% of patients with AD do not carry the APOE ε4 allele. Routine genetic testing is not recommended for late-onset AD at this time. (Choice B) An MRI of the head can be helpful to evaluate for cerebrovascular disease. However, this patient has a nonfocal neurological examination. A cognitive screening test should be performed prior to neuroimaging. (Choice D) Thiamine deficiency can cause Wernicke syndrome, which is characterized by encephalopathy (eg, confusion), oculomotor dysfunction (eg, horizontal nystagmus), and gait ataxia. This condition is most commonly seen in patients with long-term nutritional deficiency (eg, anorexia, chronic alcohol use). (Choices E and F) Thyroid function tests and vitamin B₁₂ levels are part of the workup to rule out reversible causes of dementia, but a brief, inexpensive cognitive screening tool such as the MoCA should be performed first. Educational objective: The first step in evaluation of suspected mild cognitive impairment is to perform a standardized cognitive examination using a cognitive screening tool such as the Montreal Cognitive Assessment (MoCA). Patients with evidence of possible cognitive impairment on the MoCA should undergo a workup for potentially reversible causes, which includes depression screening, laboratory evaluation, and neuroimaging. References: Is the Montreal Cognitive Assessment (MoCA) screening superior to the Mini-Mental State Examination (MMSE) in the detection of mild cognitive impairment (MCI) and Alzheimer's Disease (AD) in the elderly? (http://www.ncbi.nlm.nih.gov/pubmed/30426911)

A 65-Year-Old Woman Is Brought to the Office by Her