A 74-year-old man comes to the office due to memory problems over the past several months. He is accompanied by his wife. The patient says, "I am worried about my memory. I feel like I am losing my mind. I can't remember what I've read in the newspaper, and I even have difficulty following the plot on TV shows." His wife says, "He frequently misplaces things like his keys and wallet and can't recall names of individuals he should know. She adds, "He used to like to cook and watch TV, but he doesn't seem to enjoy these things anymore. When he attempted to make a favorite dish recently, he left out half the ingredients and burned the meal." Over the past 2 months, the patient has been involved in 2 minor car accidents in which he was "not paying attention." He recently told his wife that they are "ruined and going bankrupt," despite her multiple assurances that this is not so. She says, "I show him the bank statements, but a few days later, it's as if he doesn't remember and he asks to see them again." They went through a difficult time over the past year due to his suspicions that she had an affair, which were recently confirmed. The patient's medical history is significant for gastroesophageal reflux disease, rheumatoid arthritis, and hypertension. He has increased soreness and pain in his joints and neck that he attributes to "my body breaking down." The patient has a history of thyroid cancer that was successfully treated 15 years earlier. His medications include lisinopril, levothyroxine, hydrochlorothiazide, aspirin, and antacids. Physical examination is unremarkable. Laboratory studies, including vitamin B₁₂ and thyroid function, are normal.
Which of the following is the best response to this patient's concerns?

Question

Quizplus · Accepted Answer

Explanation: Late-life depression frequently presents with reversible cognitive impairment (pseudodementia). Patients often experience impaired executive function (planning and carrying out tasks, processing new information), impaired memory and recall, and difficulties with focus and concentration. When the underlying depression is treated, the cognitive impairment often fully resolves. When older adults with memory deficits are assessed, mood and affect should be closely examined to determine whether underlying depression could be causing these symptoms. Due to concerns about stigma or judgment, many older adults do not overtly discuss depressive feelings, which are frequently misdiagnosed. In addition to impaired memory and concentration, this patient has multiple factors that should raise clinical suspicion for depression, including his psychosocial situation, loss of interest and enjoyment, somatic symptoms, and anxious ruminations. (Choice A) A brain MRI scan is most useful for ruling out other reversible causes of dementia (eg, subdural hematoma, normal pressure hydrocephalus, treatable cancer) and would not confirm the diagnosis of Alzheimer disease or assist in diagnosing depression. Although structural neuroimaging should be considered in the evaluation of all patients with dementia, this patient's cognitive deficits are likely secondary to depression, which should be ruled out first. (Choice B) The Mini-Mental State Examination is a useful test for dementia, with a score <24 points suggestive of dementia or delirium. However, it would not be helpful in identifying depression, and a score of <24 in this patient may be due to depression-related impairment in motivation and/or concentration rather than true dementia. (Choice C) Although normal aging is associated with some memory loss, this patient's cognitive impairment is causing clear functional impairment and requires further evaluation and treatment. (Choice E) It would be premature to suggest that this patient may have Alzheimer disease before assessing him for major depression. Educational objective: Cognitive impairment is a common symptom of late-life depression and is reversible with treatment. Older adults with new-onset cognitive impairment should be assessed for depression. References: Diagnosis and treatment of depression and cognitive impairment in late life. (http://www.ncbi.nlm.nih.gov/pubmed/25655026) Depression and cognition in the elderly. (http://www.ncbi.nlm.nih.gov/pubmed/25581234)

A 74-Year-Old Man Comes to the Office Due to Memory