Medicine>>>>>Geriatrics
Question 10#

A 76-year-old man complains of memory difficulties. He has trouble remembering where he parks his car at the supermarket and struggles with the names of new acquaintances. He has no trouble managing his finances, can readily recall the names of close friends and family members, and does not get lost in familiar settings. He has hypertension managed with an ACE inhibitor and takes acetaminophen for knee pain. He is optimistic and enjoys life. His general physical examination is normal. On the Folstein Mini-Mental State Exam, he scores 27 out of a possible 30 points. He only recalls one out of three objects after a 5-minute interval. Tests of language, calculation, and executive function are normal.

What is your best course of management for this patient?

A. MRI of head to rule out mass lesion
B. Institute sertraline 50 mg daily
C. Refer for neuropsychological testing
D. Begin donepezil 10 mg daily
E. Reassure and reevaluate in 6 months

Correct Answer is E

Comment:

This patient has age-related mild cognitive dysfunction (MCI). He has a deficit in only one area of cognition, (ie, memory) with intact language, visuospatial, and executive functions and is not disabled in activities of daily living. Although 10% of such patients progress to frank dementia each year, some will improve, so progression is not inevitable. Although mental activities such as crossword puzzles have been anecdotally felt to prevent cognitive decline, there is no definitive evidence than any intervention affects the natural history of MCI. Most patients with overt dementia lose insight along with memory and do not notice their own memory deficit.

Workup for treatable causes of cognitive decline (ie, CNS imaging, electrolytes, thyroid, and B12 levels) is indicated in patients with frank dementia, but not in those with MCI. Depression can present as self-reported memory problems but should cause other symptoms such as anhedonia. Neuropsychological testing can be helpful in complicated cases but is expensive and not used routinely. Although donepezil is usually the initial therapy in Alzheimer disease, it has not been proven to prevent progression of MCI to overt dementia.