A 69-year-old woman is brought to the office by her husband due to forgetfulness. The patient is a retired law professor who taught classes until a year ago when she began to have difficulty remembering lesson plans. Since then, her memory has worsened, and she has gotten lost during her normal neighborhood walk on more than one occasion. Her husband has taken over responsibility for all cooking and cleaning; moreover, the patient is unable to drive or use public transportation on her own. Medical history is significant for hypertension and type 2 diabetes mellitus for which she takes lisinopril and metformin. The patient has no family history of memory problems. Temperature is 36.7 C (98.1 F), blood pressure is 134/74 mm Hg, pulse is 72/min, and respirations are 14/min. She scores a 22/30 on Montreal Cognitive Assessment (normal: ≥26). There are no focal neurologic deficits. Which of the following is the most appropriate next step in evaluation of this patient?

Question

A 69-year-old woman is brought to the office by her husband due to forgetfulness.  The patient is a retired law professor who taught classes until a year ago when she began to have difficulty remembering lesson plans.  Since then, her memory has worsened, and she has gotten lost during her normal neighborhood walk on more than one occasion.  Her husband has taken over responsibility for all cooking and cleaning; moreover, the patient is unable to drive or use public transportation on her own.  Medical history is significant for hypertension and type 2 diabetes mellitus for which she takes lisinopril and metformin.  The patient has no family history of memory problems.  Temperature is 36.7 C (98.1 F), blood pressure is 134/74 mm Hg, pulse is 72/min, and respirations are 14/min.  She scores a 22/30 on Montreal Cognitive Assessment (normal: ≥26).  There are no focal neurologic deficits.  Which of the following is the most appropriate next step in evaluation of this patient?

Quizplus · Accepted Answer

11ec25c8_d546_8c4b_bc81_edeab9cf056f_MD0003_00 This patient's year-long history of progressive cognitive decline and associated impairment in activities of daily living (eg, cooking, cleaning, using transportation) meets criteria for dementia (also known as major neurocognitive disorder). Her prominent memory symptoms, insidious disease course, and lack of associated neurological findings make Alzheimer disease (AD) more likely than other subtypes of dementia (eg, vascular dementia, frontotemporal dementia, dementia with Lewy bodies). AD, the most common form of dementia in older patients, is inevitably progressive and irreversible. However, before a definitive diagnosis is made, all patients should undergo a workup for potentially reversible causes of cognitive impairment. No matter which subtype is suspected, the initial evaluation of suspected dementia is similar. Evaluation involves neuropsychological testing (eg, Montreal Cognitive Assessment), laboratory testing (complete blood count, vitamin B₁₂, TSH, complete metabolic panel), and neuroimaging. The apolipoprotein E epsilon 4 allele is associated with an increased risk for AD. However, genetic testing is contraindicated for the routine evaluation of suspected dementia because it exposes patients to the potential psychological harms of false positives and false negatives without providing sufficient clinical utility. (Choices A and B) Cerebrospinal fluid testing and electroencephalogram are only indicated in patients with specific risk factors. Cerebrospinal fluid testing may be indicated when a suspected underlying infection or malignancy is believed to be contributing to the presentation. Electroencephalogram may be considered in patients with an underlying seizure disorder or in those exhibiting seizure like activity. (Choices C and F) Folate and vitamin D levels are not routinely obtained; they are indicated only in specific risk groups. For example, patients with alcohol use disorder may have folate deficiencies that can contribute to cognitive impairment. Some conditions may place a patient at risk for vitamin D deficiency (eg, celiac disease, chronic kidney disease) and may also justify targeted testing. (Choice D) Syphilis testing is indicated only in patients with specific risk factors such as those with a known exposure. Educational objective: The initial workup of suspected dementia should include neuropsychological testing (eg, Montreal Cognitive Assessment), selected laboratory testing (complete blood count, complete metabolic panel, TSH, vitamin B₁₂), and neuroimaging (eg, MRI). Patients in specific risk groups may warrant additional targeted testing. References: Dementia for the primary care provider. (http://www.ncbi.nlm.nih.gov/pubmed/28797371) Evaluation of suspected dementia. (http://www.ncbi.nlm.nih.gov/pubmed/22010769)

A 69-Year-Old Woman Is Brought to the Office by Her