A 72-year-old man complains of memory difficulties. He is worried that he has Alzheimer disease. He has trouble recalling the names of friends, and last month forgot his son's birthday, which had never happened before. On two occasions he became lost driving to a familiar department store. He is now afraid to make trips away from home. His children tell him that he has forgotten things they have discussed even 1 day previously. He lives independently and has not had any difficulty preparing meals, paying bills, using the telephone, or taking his medications. He takes lisinopril and hydrochlorothiazide for hypertension. He does not use alcohol. Folstein MMSE score is 27/30 and Montreal Cognitive Assessment (MoCA) score is 26/30. Neurologic examination is normal. Which of the following is most appropriate?
Difficulty recalling names and temporarily misplacing objects are commonly seen with advancing age but becoming lost and having trouble recalling recent conversations are more worrisome symptoms of significant cognitive impairment. This patient does not have dementia, which requires impairment in memory and one other cognitive domain (language, spatial orientation, or executive function). The Folstein mini-mental state examination (MMSE) and the Montreal Cognitive Assessment (MoCA) are screening tests for Alzheimer disease. Most authorities use MMSE and MoCA scores of less than 26 as a positive screen. This patient is on the borderline of a positive screen. Patients with isolated but significant cognitive impairment, but who do not meet the diagnostic criteria for dementia, are often classified as having mild cognitive impairment (MCI). MCI is often accompanied by depression and can be due to vitamin B12 deficiency, for which the patient should be screened. Patients with mild cognitive impairment are at higher risk for progression to frank dementia (12% per year in some series), but some of these patients will never develop progressive memory loss. Randomized trials of the acetylcholinesterase inhibitors donepezil and galantamine have failed to establish efficacy of either of these drugs in patients with MCI. Holter monitoring is used to detect cardiac arrhythmias, which can be associated with syncope but not selective memory impairment.
Inform the patient that his symptoms are a normal consequence of aging and that his risk of Alzheimer disease is no higher than average
Tell the patient that he has dementia and must stop driving
Perform screening tests for vitamin deficiency and psychiatric disease
Begin donepezil
C.N.S.