Assignment: Evaluation of Memory Problems

Assignment: Evaluation of Memory Problems

Assignment: Evaluation of Memory Problems

You are working in the internal medicine clinic today with Dr. Irving. She asks you to evaluate Mr. Caldwell, a 75-year-old male, who is here today with his daughter because of concerns about his memory raised at his last visit.

Initial Approach to Evaluation of Memory Problems

1. Focused history

2. Cognitive assessment

3. Functional evaluation

You go to the exam room and introduce yourself to Mr. Caldwell. He responds, “Happy to meet you. This is my daughter Kathy.”

After you’ve greeted them both briefly, you begin asking Mr. Caldwell questions about his memory.

Focused History

“How long have you been having problems with your memory?”

“Oh, I have the same memory problems as any 75-year-old. Occasionally, I forget my keys or forget something at the grocery store. But I still remember my wedding day and I still remember my grandchildren’s names. I’m not doing any worse than any of my friends.”

“Have you had any trouble keeping up with your finances or medications?”

“Well, my wife used to manage the money until she died two years ago. I have trouble with the numbers in my checkbook and trouble figuring out my medications so Kathy takes care of these things for me now.”

After this initial questioning, you proceed with your cognitive evaluation.

The MoCA test is administered to Mr. Caldwell. He achieves a score of 17, suggesting moderate impairment.

Based on Mr. Caldwell’s score, how would you classify his memory loss? Choose the single best answer.

The best option is indicated below. Your selections are indicated by the shaded boxes.

· A. Delerium

· B. Depression

· C. Major neurocognitive disorder

· D. Mild neurocognitive disorder

· E. Normal aging

SUBMIT

Answer Comment

> The correct answer is C

Mr. Caldwell has a score of 17 and by his history has problems in at least one DSM-5 cognitive domain. In addition, some of his instrumental activities of daily living like managing his medications and finances are now not possible. He is classified as having Major Neurocognitive Disorder (C).

TEACHING POINT

Major Neurocognitive Disorder

The main subtypes of major neurocognitive impairment that classify as forms of dementia are as follows:

· Alzheimer disease

· Vascular disease / dementia

· Lewy body dementia

· Frontotemporal lobar degeneration

The additional subtypes are as follows:

· Parkinson disease

· Traumatic brain injury

· HIV

· Prion disease

· Huntington disease

· Substance/medication use

· Other medical condition

· Multiple etiologies

Prevalence

The DSM-5 estimates that the prevalence of major neurocognitive disorder (which they use congruently with the term dementia) vary across ages.

The prevalence of Major Neurocognitive Disorder is approximately 1-2% at age 65 and as high as 30% by age 85.

The prevalence of Mild Neurocognitive Disorder ranges from 2-10% at age 65 and from 5-25% by age 85.

Development and Course:

When due to neurodegenerative conditions like the common forms of dementia, the onset of symptoms is usually insidious and gradual. Later in life if may be difficult to distinguish normal aging from prodromal phases of Mild Neurocognitive Disorder. In addition, given the high prevalence of other medical conditions in older individuals, the symptoms of these conditions often go unnoticed or are overlooked due to the coexisting problems.

Risk Factors:

Age is the most common risk factor since increased age leads to greater neurodegenerative and cerebrovascular disease. Females are also more prone to developing these conditions, although this may be due to their overall increased lifespan.

After Mr. Caldwell grants you permission, you ask his daughter a couple of questions about his activities of daily living:

“Have you noticed that your father has any trouble with his memory?”

“I definitely think he’s having some trouble. He has a lot more trouble remembering new information. He’s right, he does remember things that happened a long time ago, like his wedding, and he knows all of his grandkids. However, last week he forgot what he needed at the store and he has missed some bills and occasionally forgets his medications.”

“Is he able to prepare his own meals?”

“Dad makes his own meals and eats well – he was always the cook in the family. He can do his laundry and take care of the house. He doesn’t drive or get out much because he doesn’t have a car and he has some trouble with his balance because of his knee pain, so my husband and I or our kids take him on most of his errands.”

TEACHING POINT

Functional Assessment: Activities of Daily Living

Activities of daily living (ADLs) are divided into two subcategories: basic and instrumental (IADLs)

The patient’s family members may be very helpful with this information.

Question

Which of the following basic or instrumental ADLs are likely to be affected early in the course of dementia? Select all that apply.

The best options are indicated below. Your selections are indicated by the shaded boxes.

· A. Bathing

· B. Doing laundry

· C. Dressing

· D. Managing finances

· E. Managing medications

Now that you have gained some information about Mr. Caldwell’s memory, you take a second to review his medical history with Mr. Caldwell and his daughter:

Active problems

Active problems:

1. Hypertension

2. Occasional insomnia

3. Hyperlipidemia

4. Osteoarthritis

Social history / habits

Social history / habits:

· retired high school librarian

· lives at home alone

· widowed for 2 years

· 2 close friends in his apartment complex

· never smoked

· occasional alcohol around holidays only, never excessive.

Medications

Current medications:

1. Hydrochlorothiazide 25 mg by mouth once a day.

2. Amlodipine 5 mg by mouth once a day.

3. Lorazepam 2 mg by mouth before bed as needed for insomnia (takes 2-3 times/week).

4. Acetaminophen 500 mg – two tablets by mouth three times per day.

5. Lovastatin 40 mg by mouth once a day. Assignment: Evaluation of Memory Problems