An 85-year-old man comes to the office for a routine health evaluation. The patient lives independently but is accompanied by his daughter who does his grocery shopping and visits him weekly. The daughter is concerned that her father seems increasingly withdrawn and forgetful over the past year. She reports that he does not socialize with his neighborhood friends as much as he used to and calls her less frequently. "When we do speak, he often seems to forget what I just told him and repeats the same question that I've just answered." The patient admits that he sometimes forgets names but attributes this to "old age." He denies any changes in mood, sleep, or appetite. Medical history includes hypertension and osteoarthritis of the knees. Current medications include hydrochlorothiazide and ibuprofen. Vital signs are within normal limits, and physical examination is unremarkable. The patient is pleasant and cooperative and speaks loudly. Montreal Cognitive Assessment score is 26/30. Which of the following is the most appropriate next step in management of this patient?

Question

An 85-year-old man comes to the office for a routine health evaluation.  The patient lives independently but is accompanied by his daughter who does his grocery shopping and visits him weekly.  The daughter is concerned that her father seems increasingly withdrawn and forgetful over the past year.  She reports that he does not socialize with his neighborhood friends as much as he used to and calls her less frequently.  "When we do speak, he often seems to forget what I just told him and repeats the same question that I've just answered."  The patient admits that he sometimes forgets names but attributes this to "old age."  He denies any changes in mood, sleep, or appetite.  Medical history includes hypertension and osteoarthritis of the knees.  Current medications include hydrochlorothiazide and ibuprofen.  Vital signs are within normal limits, and physical examination is unremarkable.  The patient is pleasant and cooperative and speaks loudly.  Montreal Cognitive Assessment score is 26/30.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Age-related hearing loss (presbycusis) is extremely common, affecting more than half of all adults age ≥75. Some patients may be unaware of their deficits when hearing loss progresses slowly. Rather than seeking help for hearing loss, these patients may come in or be brought in with increasing social isolation and cognitive difficulties as they avoid engaging in conversations and misunderstand what is being said. This patient's presentation includes several clues for hearing loss, including withdrawal from his neighborhood friends, fewer telephone calls to his daughter, repeated questions, and loud speaking; his daughter's impression that he forgets what she just told him (whereas he may have misheard or misunderstood what she had said) is likely a further reflection of presbycusis. Other clues for age-related hearing loss include turning the television or radio volume up and difficulty hearing in a crowd or when background noise is present. If not addressed, age-related hearing loss can lead to increasing loneliness, depression, cognitive impairment, and functional disability. The most appropriate next step is to take a careful history of hearing changes and perform a whispered voice test. Audiometric testing can be used to confirm the diagnosis (if necessary) and direct management (eg, hearing aids, cochlear implants). (Choice A) Although depression can also cause social isolation and cognitive impairment, it is typically accompanied by other symptoms, such as changes in mood, sleep, and appetite, which are not present in this case. (Choice C) A home geriatric assessment identifies and coordinates planning for older adults with significant medical, psychosocial, and functional disabilities (eg, hip fracture, increased fall risk, depression, cognitive decline, those at risk for high use of health care services). A simple screen for hearing loss should precede an intensive evaluation in this patient. (Choices D and F) An MRI scan of the brain and thyroid function testing would be appropriate in the workup for suspected dementia. However, this patient's cognitive assessment score is within normal limits; a score ≤24/30 is generally used as a cutoff for significant cognitive impairment. Forgetting names occasionally is consistent with normal age-related changes. In addition, the patient has no additional signs or symptoms that suggest neurologic or thyroid dysfunction. (Choice E) It would be inappropriate to dismiss the daughter's concerns about her father's social withdrawal and cognitive difficulties without an evaluation for treatable conditions, such as hearing loss. Educational objective: Hearing loss in the elderly is common and may present with social isolation and cognitive decline. Careful history-taking and a whispered voice test should be conducted. Audiometric testing can help confirm the diagnosis and direct management. References: Age-related hearing loss and cognitive decline - the potential mechanisms linking the two. (http://www.ncbi.nlm.nih.gov/pubmed/30177417) Sensation and psychiatry: linking age-related hearing loss to late-life depression and cognitive decline. (http://www.ncbi.nlm.nih.gov/pubmed/29202654) Hearing loss in the elderly. (http://www.ncbi.nlm.nih.gov/pubmed/29661329)

An 85-Year-Old Man Comes to the Office for a Routine