Assessment of the forgetful older patient: history and investigations

What it is

Assessment of the older patient who has become forgetful runs along two lines: the history, and a set of investigations grouped as biological, psychological and social. The history is what allows the differential diagnoses to be prioritized, and the three to weigh against one another are delirium, dementia and pseudodementia.

The interview itself carries marks. The interviewer introduces himself or herself, states the aim of the interview, and is marked on rapport, empathy and style, and on the overall approach.

How it is diagnosed

Onset, duration and progression of the forgetfulness come first, then the type of memory affected: recent against remote. Remote events are such things as a date of birth or a national date, while recent ones are the place of the keys and other personal items. Forgetting keys, forgetting phones and praying repeatedly are the kind of thing meant.

The rest of the history covers:

• Difficulties in recognition, such as inability to recognize a close family member or inability to recognize items.
• Language impairment: word finding difficulties, unable to initiate or maintain conversation, impaired comprehension.
• Ability to perform purposive actions, such as dressing, eating and toileting.
• Executive functions, such as shopping, managing finance and planning a visit.
• Basic and instrumental activities of daily living. Basic covers bathing, toileting and eating; instrumental covers using the phone, preparing a meal and laundry.
• Mood symptoms, meaning sad, irritable, easily provoked and isolation, together with their relationship to the current forgetfulness and confusion.
• Psychotic symptoms: suspiciousness, for example believing that others steal properties, and hallucinations, such as hearing voices, experiencing abnormal visual images, or muttering to self.
• Confusion and associated symptoms: loss of consciousness, fever, seizure and perceptual changes.
• Behavioral or perceptual changes, and the impact of the condition on function and activities of daily living such as bathing, eating and transportation.
• Past medical history of diabetes, hypertension and stroke; past psychiatric history of depression; current medications; family history of dementia and other disorders; smoking and alcohol.

Investigations are arranged the same three ways: 1) biological, CBC, RFT, LFT, TFT, lipid profile and fasting glucose, VDRL and HIV, serum levels of Vit. B12 and folate, and if clinically indicated a CT scan, EEG and LP; 2) psychological, where a score below 24 on the mini mental state examination (MMSE) means dementia is possible, though the MMSE is a screening test and is not diagnostic, and the Montreal cognitive assessment (MOCA) is more useful than it; 3) social, home visits for further assessment of the patient at the community level, for the presence of financial support, the safety of the environment, and basic and instrumental activities of daily living.